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Cucchi M, Mariani S, Kawczynski MJ, Shkurka E, Ius F, Comentale G, Hoskote A, Lorusso R. Individual patient data meta-analysis on awake pediatric extracorporeal life support: Feasibility and safety of analgesia, sedation and respiratory support weaning, and physiotherapy. Perfusion 2024:2676591241240377. [PMID: 38652693 DOI: 10.1177/02676591241240377] [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: 04/25/2024]
Abstract
OBJECTIVE Awake Extracorporeal Life Support (aECLS) with active mobilization has gained consensus over time, also within the pediatric community. This individual patient data (IPD) meta-analysis summarizes available evidence on pediatric aECLS, its feasibility, and safety regarding sedation weaning, extubation, and physiotherapy. METHODS PubMed/Medline and Cochrane Database were screened until February 2022. Articles reporting on children (≤18 years) undergoing aECLS were selected. IPD were requested, pooled in a single database, and analyzed using descriptive statistics. Primary outcome was survival to hospital discharge. Secondary outcomes included extubation during ECLS, physiotherapy performed, tracheostomy, and complications. RESULTS Nineteen articles and 65 patients (males:n = 30/59,50.8%) were included. Age ranged from 2 days to 17 years. ECLS configurations included veno-venous (n = 42/65, 64.6%), veno-arterial (n = 18/65, 27.7%) and other ECLS settings (n = 5/65, 7.7%). Exclusive neck cannulation was performed in 51/65 (78.5%) patients. Extubation or tracheostomy during ECLS was reported in 66.2% (n = 43/65) and 27.7% (n = 18/65) of patients, respectively. Physiotherapy was reported as unspecified physical activity (n = 34/63, 54%), mobilization in bed (n = 15/63, 23.8%), ambulation (n = 14/63, 22.2%). Complications were reported in 60.3% (n = 35/58) of patients, including hemorrhagic (36.2%), mechanical (17.2%), or pulmonary (17.2%) issues, and need for reintubation (15.5%). Survival at discharge was 81.5% (n = 53/65). CONCLUSION Awake ECLS strategy with active physiotherapy can be applied in children from neonatal age. Ambulation is also possible in selected cases. Complications related to such management were limited. Further studies on aECLS are needed to evaluate safety and efficacy of early physiotherapy and define patient selection.
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Affiliation(s)
- Marta Cucchi
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
- Pediatric Intensive Care Unit, Queensland Children Hospital, Brisbane, QLD, Australia
| | - Silvia Mariani
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Michal J Kawczynski
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Emma Shkurka
- Pediatric Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Fabio Ius
- Department of Cardiothoracic, Transplant, and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Giuseppe Comentale
- IRCCS Policlinico Universitario Sant'Orsola-Malpighi, Alma Mater Studiorum University of Bologna, Bologna, Italy
| | - Aparna Hoskote
- Pediatric Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Roberto Lorusso
- ECLS Centrum, Cardio-Thoracic Surgery Department, Heart & Vascular Center, Maastricht University Medical Center, and Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
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Shkurka E, Child H, Balls J, Melkhuln E, Carter L, Compton V, Marscheider R, McConnell R, Meenaghan S, Milburn N, Nugent G, Peabody G, Rimmer L. Early rehabilitation and mobilisation of neonatal and paediatric extracorporeal membrane oxygenation patients: A UK and Ireland consensus document. Perfusion 2024; 39:174-181. [PMID: 36240012 DOI: 10.1177/02676591221132676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Despite increasing early rehabilitation and mobilisation (ERM) in paediatric intensive care, current evidence for ERM of neonatal and paediatric patients receiving extracorporeal membrane oxygenation (ECMO) is limited. The proposed benefits of ERM in neonatal and paediatric ECMO patients are multifaceted, including reduced immobility related issues and maintenance of functional ability. However, ECMO presents additional safety and logistical challenges, and currently there are no published neonatal or paediatric guidelines. A consensus document was developed to provide guidance for ERM with neonatal and paediatric ECMO patients. The document was developed by specialist physiotherapists from nine ECMO centres within the UK and Ireland, together with the UK Paediatric Critical Care Society ECMO group and members of the multidisciplinary team. The document covers key considerations and practicalities for completing ERM in this population including, acuity level measurement, activity level guidance, safety and risk assessment, and goal setting. Risk assessment and safety checklist bedside tools are also included and designed to be adapted as required to meet specific unit policies and protocols.
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Affiliation(s)
- Emma Shkurka
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Hannah Child
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Jennie Balls
- Royal Brompton and Harefield NHS Trust, London, UK
| | - Ellie Melkhuln
- Evelina London Children's Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Lee Carter
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | | | | | - Rachel McConnell
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle, UK
| | | | - Natalie Milburn
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | | | - Gemma Peabody
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Laura Rimmer
- Alder Hey Children's NHS Foundation Trust, Liverpool, UK
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3
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Thatch KA, Kays DW. Advances in pulmonary management and weaning from ECLS. Semin Pediatr Surg 2023; 32:151329. [PMID: 37866170 DOI: 10.1016/j.sempedsurg.2023.151329] [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: 10/24/2023]
Abstract
ECMO for neonatal and pediatric respiratory failure provides gas exchange to allow lung recovery from reversible pulmonary ailments. This is a comprehensive discussion on the various strategies and advances utilized by pediatric ECLS specialists today. ECMO patients require continual monitoring, serial gasses and radiographs, near-infrared spectroscopy (NIRS - to monitor oxygen delivery to regional tissue beds), and more quality ECLS directed care. As the foundation to lung recovery, good EMCO closely monitors ECLS flow rates, sweep gasses, and membrane lung function. Mixed venous oxygen saturation (Sv02) greater than 65% indicates good oxygen delivery and sweep gas adjustments maintain PaCO2 of 40-45 mm Hg. Lung recovery ventilatory settings do not fully rest the lungs but maintain normal or nontoxic pressure and oxygen levels. Neonatal recovery settings are PIP (cm H20) of 15-20, PEEP of 5-10, ventilator rate of 12-20 and an inspiratory time of 0.5-1 s, and FiO2 of 0.3-0.5. Pediatric recovery settings are PIP (cm H20) < 25, PEEP of 5-15, ventilator rate of 10-20 and an inspiratory time of 0.8-1 s, and FiO2 of <0.5. Some studies demonstrate a higher recovery PEEP level decreases duration of ECMO, but do not demonstrate a mortality difference. Multiple adjunctive therapies such as surfactant, routine pulmonary clearance and respiratory physiotherapy, iNO, prone positioning, bronchoscopy, POCUS, CT imaging, and extubation or "awake ECLS" can significantly affect pulmonary recovery. Patience is necessary as lung recovery may take weeks or even months on the nontoxic settings. On these settings, dynamic recovery will be revealed by improvement in tidal volume, minute ventilation and radiographic pulmonary aeration, prompting discussion about weaning. When this pulmonary compliance recovery becomes evident, decreasing ECLS flow while also decreasing circuit FiO2 and/or sweep gas are common components to ECMO weaning strategies.
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Affiliation(s)
- Keith A Thatch
- Department of Pediatric Surgery, John Hopkins All Children's Hospital, St. Petersburg, FL, USA.
| | - David W Kays
- Department of Pediatric Surgery, John Hopkins All Children's Hospital, St. Petersburg, FL, USA
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Johnson B, Dobkin SL, Josephson M. Extracorporeal membrane oxygenation as a bridge to transplant in neonates with fatal pulmonary conditions: A review. Paediatr Respir Rev 2022; 44:31-39. [PMID: 36464576 DOI: 10.1016/j.prrv.2022.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 11/10/2022] [Indexed: 11/15/2022]
Abstract
Neonates with progressive respiratory failure should be referred early for subspecialty evaluation and lung transplantation consideration. ECMO should be considered for patients with severe cardiopulmonary dysfunction and a high likelihood of death while on maximal medical therapy, either in the setting of reversible medical conditions or while awaiting lung transplantation. While ECMO offers hope to neonates that experience clinical deterioration while awaiting transplant, the risks and benefits of this intervention should be considered on an individual basis. Owing to the small number of infant lung transplants performed yearly, large studies examining the outcomes of various bridging techniques in this age group do not exist. Multiple single-centre experiences of transplanted neonates have been described and currently serve as guidance for transplant teams. Future investigation of outcomes specific to neonatal transplant recipients bridged with advanced devices is needed.
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Affiliation(s)
- Brandy Johnson
- Division of Pediatric Pulmonary Medicine, UF Health Shands Children's Hospital, Gainesville, FL, USA; Department of Pediatrics, University of Florida College of Medicine, Gainesville, FL, USA.
| | - Shoshana Leftin Dobkin
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
| | - Maureen Josephson
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Management of the CDH patient on ECLS. Semin Fetal Neonatal Med 2022; 27:101407. [PMID: 36411199 DOI: 10.1016/j.siny.2022.101407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Congenital diaphragmatic hernia (CDH) is the most common indication for respiratory extracorporeal life support (ECLS) in neonates. The survival rate of CDH neonates treated with ECLS is 50%, and this figure has remained relatively stable over the last few decades. This is likely because the current population of CDH neonates who require ECLS have a higher risk profile [1]. The management of neonates with CDH has evolved over time to emphasize postnatal stabilization, gentle ventilation, and multi-modal treatment of pulmonary hypertension. In order to minimize practice variation, many centers have adopted CDH-specific clinical practice guidelines, however care is not standardized between different centers and outcomes vary [3]. The purpose of this review is to summarize our current understanding of issues central to the care of neonates with CDH treated with ECLS and specifically highlight how the use of the Extracorporeal Life Support Organization (ELSO) data have added to our understanding of CDH.
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Ventilation Strategies During Extracorporeal Membrane Oxygenation for Neonatal Respiratory Failure: Current Approaches Among Level IV Neonatal ICUs. Crit Care Explor 2022; 4:e0779. [DOI: 10.1097/cce.0000000000000779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Abstract
Neonatal and pediatric extracorporeal membrane oxygenation (ECMO) has evolved over the past 50 years. Advances in technology, expertise, and application have increased the number of centers providing ECMO with expanded indications for use. However, increasing the use of ECMO in recent years to more medically complex critically ill children has not changed overall survival despite increased experience and improvements in technology. This review focuses on ECMO history, circuits, indications and contraindications, management, complications, and outcome data. The authors highlight important areas of progress, including unintubated and awake patients on ECMO, application during the COVID-19 pandemic, and future directions.
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Affiliation(s)
- Katherine Cashen
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke Children's Hospital, Durham, NC, USA; Duke University Medical Center, 2301 Erwin Road, Suite 5260Y, DUMC 3046, Durham, NC 27710, USA.
| | - Katherine Regling
- Division of Pediatric Hematology Oncology, Children's Hospital of Michigan, 3901 Beaubien Boulevard, Detroit, MI 48201, USA; Central Michigan University, Mt. Pleasant, MI, USA
| | - Arun Saini
- Division of Pediatric Critical Care Medicine, Texas Children's Hospital, 6651 Main Street, Suite 1411, Houston, TX 77030, USA; Baylor University School of Medicine, Houston, TX, USA
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Kohne JG, MacLaren G, Rider E, Carr B, Mallory P, Gebremariam A, Friedman M, Barbaro RP. Tracheostomy Practices and Outcomes in Children During Respiratory Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2022; 23:268-276. [PMID: 35081085 PMCID: PMC9197266 DOI: 10.1097/pcc.0000000000002902] [Citation(s) in RCA: 4] [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: 11/26/2022]
Abstract
OBJECTIVES Children receiving prolonged extracorporeal membrane oxygenation (ECMO) support may benefit from tracheostomy during ECMO by facilitating rehabilitation; however, the procedure carries risks, especially hemorrhagic complications. Knowledge of tracheostomy practices and outcomes of ECMO-supported children who undergo tracheostomy on ECMO may inform decision-making. DESIGN Retrospective cohort study. SETTING ECMO centers contributing to the Extracorporeal Life Support Organization registry. PATIENTS Children from birth to 18 years who received ECMO support for greater than or equal to 7 days for respiratory failure from January 1, 2015, to December 31, 2019. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Three thousand six hundred eighty-five children received at least 7 days of ECMO support for respiratory failure. The median duration of ECMO support was 13.0 days (interquartile range [IQR], 9.3-19.9 d), and inhospital mortality was 38.7% (1,426/3,685). A tracheostomy was placed during ECMO support in 94/3,685 (2.6%). Of those who received a tracheostomy on ECMO, the procedure was performed at a median 13.2 days (IQR, 6.3-25.9 d) after initiation of ECMO. Surgical site bleeding was documented in 26% of children who received a tracheostomy (12% after tracheostomy placement). Among children who received a tracheostomy, the median duration of ECMO support was 24.2 days (IQR, 13.0-58.7 d); inhospital mortality was 30/94 (32%). Those that received a tracheostomy before 14 days on ECMO were older (median age, 15.8 yr [IQR, 4.7-15.5] vs 11.7 yr [IQR, 11.5-17.3 yr]; p =0.002) and more likely to have been supported on venovenous-ECMO (84% vs 52%; p = 0.001). Twenty-two percent (11/50) of those who received a tracheostomy before 14 days died in the hospital, compared with 19/44 (43%) of those who received a tracheostomy at 14 days or later (p = 0.03). CONCLUSIONS Tracheostomies during ECMO were uncommon in children. One in four patients who received a tracheostomy on ECMO had surgical site bleeding. Children who had tracheostomies placed after 14 days were younger and had worse outcomes, potentially representing tracheostomy as a "secondary" strategy for prolonged ECMO support.
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Affiliation(s)
- Joseph G. Kohne
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Health System, Singapore
- Pediatric Intensive Care Unit, Royal Children’s Hospital, Melbourne, Australia
| | - Erica Rider
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan
| | | | | | - Acham Gebremariam
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, Michigan
| | | | - Ryan P Barbaro
- Division of Critical Care Medicine, Department of Pediatrics, University of Michigan
- Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, Michigan
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Amodeo I, Di Nardo M, Raffaeli G, Kamel S, Macchini F, Amodeo A, Mosca F, Cavallaro G. Neonatal respiratory and cardiac ECMO in Europe. Eur J Pediatr 2021; 180:1675-1692. [PMID: 33547504 PMCID: PMC7864623 DOI: 10.1007/s00431-020-03898-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 11/28/2022]
Abstract
Neonatal extracorporeal membrane oxygenation (ECMO) is a life-saving procedure for critically ill neonates suffering from a potentially reversible disease, causing severe cardiac and/or respiratory failure and refractory to maximal conventional management. Since the 1970s, technology, management, and clinical applications of neonatal ECMO have changed. Pulmonary diseases still represent the principal neonatal diagnosis, with an overall 74% survival rate, and up to one-third of cases are due to congenital diaphragmatic hernia. The overall survival rate in cardiac ECMO is lower, with congenital heart defect representing the main indication. This review provides an overview of the available evidence in the field of neonatal ECMO. We will address the changing epidemiology, basic principles, technologic advances in circuitry, and monitoring, and deliver a current multidisciplinary management framework, focusing on ECMO applications, complications, and long-term morbidities. Lastly, areas for further research will be highlighted.Conclusions: ECMO is a life support with a potential impact on long-term patients' outcomes. In the next years, advances in knowledge, technology, and expertise may push neonatal ECMO boundaries towards more premature and increasingly complex infants, with the final aim to reduce the burden of ECMO-related complications and improve overall patients' outcomes. What is Known: • ECMO is a life-saving option in newborns with refractory respiratory and/or cardiac failure. • The multidisciplinary ECMO management is challenging and may expose neonates to complications with an impact on long-term outcomes. What is New: • Advances in technology and biomaterials will improve neonatal ECMO management and, eventually, the long-term outcome of these complex patients. • Experimental models of artificial placenta and womb technology are under investigation and may provide clinical translation and future research opportunities.
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Affiliation(s)
- Ilaria Amodeo
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | | | - Genny Raffaeli
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Shady Kamel
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
- Betamed Perfusion Service, Rome, Italy
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Amodeo
- ECMO & VAD Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
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Fallon BP, Gadepalli SK, Hirschl RB. Pediatric and neonatal extracorporeal life support: current state and continuing evolution. Pediatr Surg Int 2021; 37:17-35. [PMID: 33386443 PMCID: PMC7775668 DOI: 10.1007/s00383-020-04800-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/26/2020] [Indexed: 12/24/2022]
Abstract
The use of extracorporeal life support (ECLS) for the pediatric and neonatal population continues to grow. At the same time, there have been dramatic improvements in the technology and safety of ECLS that have broadened the scope of its application. This article will review the evolving landscape of ECLS, including its expanding indications and shrinking contraindications. It will also describe traditional and hybrid cannulation strategies as well as changes in circuit components such as servo regulation, non-thrombogenic surfaces, and paracorporeal lung-assist devices. Finally, it will outline the modern approach to managing a patient on ECLS, including anticoagulation, sedation, rehabilitation, nutrition, and staffing.
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Affiliation(s)
- Brian P Fallon
- Department of Surgery, ECLS Laboratory, B560 MSRB II/SPC 5686, Michigan Medicine, University of Michigan, 1150 W. Medical Center Drive, Ann Arbor, MI, 48109, USA.
| | - Samir K Gadepalli
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Ronald B Hirschl
- Department of Surgery, Section of Pediatric Surgery, University of Michigan, Ann Arbor, MI, USA
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