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Kalra A, Bachina P, Shou BL, Hwang J, Barshay M, Kulkarni S, Sears I, Eickhoff C, Bermudez CA, Brodie D, Ventetuolo CE, Kim BS, Whitman GJR, Abbasi A, Cho SM. Predicting Acute Brain Injury in Venoarterial Extracorporeal Membrane Oxygenation Patients with Tree-Based Machine Learning: Analysis of the Extracorporeal Life Support Organization Registry. RESEARCH SQUARE 2024:rs.3.rs-3848514. [PMID: 38260374 PMCID: PMC10802703 DOI: 10.21203/rs.3.rs-3848514/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2024]
Abstract
Objective To determine if machine learning (ML) can predict acute brain injury (ABI) and identify modifiable risk factors for ABI in venoarterial extracorporeal membrane oxygenation (VA-ECMO) patients. Design Retrospective cohort study of the Extracorporeal Life Support Organization (ELSO) Registry (2009-2021). Setting International, multicenter registry study of 676 ECMO centers. Patients Adults (≥18 years) supported with VA-ECMO or extracorporeal cardiopulmonary resuscitation (ECPR). Interventions None. Measurements and Main Results Our primary outcome was ABI: central nervous system (CNS) ischemia, intracranial hemorrhage (ICH), brain death, and seizures. We utilized Random Forest, CatBoost, LightGBM and XGBoost ML algorithms (10-fold leave-one-out cross-validation) to predict and identify features most important for ABI. We extracted 65 total features: demographics, pre-ECMO/on-ECMO laboratory values, and pre-ECMO/on-ECMO settings.Of 35,855 VA-ECMO (non-ECPR) patients (median age=57.8 years, 66% male), 7.7% (n=2,769) experienced ABI. In VA-ECMO (non-ECPR), the area under the receiver-operator characteristics curves (AUC-ROC) to predict ABI, CNS ischemia, and ICH was 0.67, 0.67, and 0.62, respectively. The true positive, true negative, false positive, false negative, positive, and negative predictive values were 33%, 88%, 12%, 67%, 18%, and 94%, respectively for ABI. Longer ECMO duration, higher 24h ECMO pump flow, and higher on-ECMO PaO2 were associated with ABI.Of 10,775 ECPR patients (median age=57.1 years, 68% male), 16.5% (n=1,787) experienced ABI. The AUC-ROC for ABI, CNS ischemia, and ICH was 0.72, 0.73, and 0.69, respectively. The true positive, true negative, false positive, false negative, positive, and negative predictive values were 61%, 70%, 30%, 39%, 29% and 90%, respectively, for ABI. Longer ECMO duration, younger age, and higher 24h ECMO pump flow were associated with ABI. Conclusions This is the largest study predicting neurological complications on sufficiently powered international ECMO cohorts. Longer ECMO duration and higher 24h pump flow were associated with ABI in both non-ECPR and ECPR VA-ECMO.
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Affiliation(s)
| | | | | | | | | | | | - Isaac Sears
- Warren Alpert Medical School of Brown University
| | | | | | | | | | - Bo Soo Kim
- Johns Hopkins University School of Medicine
| | | | - Adeel Abbasi
- Warren Alpert Medical School of Brown University
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Chilcote D, Sriram A, Slovis J, Morgan RW, Schaubel DE, Connelly J, Berg RA, Keim G, Yehya N, Kilbaugh T, Himebauch AS. Venovenous Extracorporeal Membrane Oxygenation Initiation for Pediatric Acute Respiratory Distress Syndrome With Cardiovascular Instability is Associated With an Immediate and Sustained Decrease in Vasoactive-Inotropic Scores. Pediatr Crit Care Med 2024; 25:e41-e46. [PMID: 37462429 PMCID: PMC10768839 DOI: 10.1097/pcc.0000000000003325] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2023]
Abstract
OBJECTIVE To determine the association of venovenous extracorporeal membrane oxygenation (VV-ECMO) initiation with changes in vasoactive-inotropic scores (VISs) in children with pediatric acute respiratory distress syndrome (PARDS) and cardiovascular instability. DESIGN Retrospective cohort study. SETTING Single academic pediatric ECMO center. PATIENTS Children (1 mo to 18 yr) treated with VV-ECMO (2009-2019) for PARDS with need for vasopressor or inotropic support at ECMO initiation. MEASUREMENTS AND MAIN RESULTS Arterial blood gas values, VIS, mean airway pressure (mPaw), and oxygen saturation (Sp o2 ) values were recorded hourly relative to the start of ECMO flow for 24 hours pre-VV-ECMO and post-VV-ECMO cannulation. A sharp kink discontinuity regression analysis clustered by patient tested the difference in VISs and regression line slopes immediately surrounding cannulation. Thirty-two patients met inclusion criteria: median age 6.6 years (interquartile range [IQR] 1.5-11.7), 22% immunocompromised, and 75% had pneumonia or sepsis as the cause of PARDS. Pre-ECMO characteristics included: median oxygenation index 45 (IQR 35-58), mPaw 32 cm H 2o (IQR 30-34), 97% on inhaled nitric oxide, and 81% on an advanced mode of ventilation. Median VIS immediately before VV-ECMO cannulation was 13 (IQR 8-25) with an overall increasing VIS trajectory over the hours before cannulation. VISs decreased and the slope of the regression line reversed immediately surrounding the time of cannulation (robust p < 0.0001). There were pre-ECMO to post-ECMO cannulation decreases in mPaw (32 vs 20 cm H 2o , p < 0.001) and arterial P co2 (64.1 vs 50.1 mm Hg, p = 0.007) and increases in arterial pH (7.26 vs 7.38, p = 0.001), arterial base excess (2.5 vs 5.2, p = 0.013), and SpO 2 (91% vs 95%, p = 0.013). CONCLUSIONS Initiation of VV-ECMO was associated with an immediate and sustained reduction in VIS in PARDS patients with cardiovascular instability. This VIS reduction was associated with decreased mPaw and reduced respiratory and/or metabolic acidosis as well as improved oxygenation.
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Affiliation(s)
- Daniel Chilcote
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Anant Sriram
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Julia Slovis
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Ryan W. Morgan
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Douglas E. Schaubel
- Department of Biostatistics, Epidemiology and Informatics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
| | - James Connelly
- ECMO Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Robert A. Berg
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Garrett Keim
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Todd Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- ECMO Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
| | - Adam S. Himebauch
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Perelman School of Medicine at the University of Pennsylvania, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
- ECMO Center, The Children’s Hospital of Philadelphia, Philadelphia, PA, United States
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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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Zens T, Ochoa B, Eldredge RS, Molitor M. Pediatric venoarterial and venovenous ECMO. Semin Pediatr Surg 2023; 32:151327. [PMID: 37956593 DOI: 10.1016/j.sempedsurg.2023.151327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is an invaluable resource in the treatment of critically ill children with cardiopulmonary failure. To date, over 36,000 children have been placed on ECMO and the utilization of this life saving treatment continues to expand with advances in ECMO technology. This article offers a review of pediatric ECMO including modes and sites of ECMO cannulation, indications and contraindications, and cannulation techniques. Furthermore, it summarizes the basic principles of pediatric ECMO including circuit maintenance, nutritional support, and clinical decision making regarding weaning pediatric ECMO and decannulation. Finally, it gives an overview of common pediatric ECMO complications including overall mortality and long-term outcomes of ECMO survivors. The goal of this article is to provide a comprehensive review for healthcare professionals providing care for pediatric ECMO patients.
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Affiliation(s)
- Tiffany Zens
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - Brielle Ochoa
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - R Scott Eldredge
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States
| | - Mark Molitor
- Phoenix Children's Hospital, Department of Surgery, Divison of Pediatric Surgery, Phoenix, AZ, United States.
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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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Abruzzo A, Gorantla V, Thomas SE. Venous thromboembolic events in the setting of extracorporeal membrane oxygenation support in adults: A systematic review. Thromb Res 2022; 212:58-71. [DOI: 10.1016/j.thromres.2022.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Revised: 02/01/2022] [Accepted: 02/18/2022] [Indexed: 01/04/2023]
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Cui Y, Zhang Y, Dou J, Shi J, Zhao Z, Zhang Z, Chen Y, Cheng C, Zhu D, Quan X, Zhu X, Huang W. Venovenous vs. Venoarterial Extracorporeal Membrane Oxygenation in Infection-Associated Severe Pediatric Acute Respiratory Distress Syndrome: A Prospective Multicenter Cohort Study. Front Pediatr 2022; 10:832776. [PMID: 35391748 PMCID: PMC8982932 DOI: 10.3389/fped.2022.832776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been increasingly used as rescue therapy for severe pediatric acute respiratory distress syndrome (PARDS) over the past decade. However, a contemporary comparison of venovenous (VV) and venoarterial (VA) ECMO in PARDS has yet to be well described. Therefore, the objective of our study was to assess the difference between VV and VA ECMO in efficacy and safety for infection-associated severe PARDS patients. METHODS This prospective multicenter cohort study included patients with infection-associated severe PARDS who received VV or VA ECMO in pediatric intensive care units (PICUs) of eight university hospitals in China between December 2018 to June 2021. The primary outcome was in-hospital mortality. Secondary outcomes included ECMO weaning rate, duration of ECMO and mechanical ventilation (MV), ECMO-related complications, and hospitalization costs. RESULTS A total of 94 patients with 26 (27.66%) VV ECMO and 68 (72.34%) VA ECMO were enrolled. Compared to the VA ECMO patients, VV ECMO patients displayed a significantly lower in-hospital mortality (50 vs. 26.92%, p = 0.044) and proportion of neurologic complications, shorter duration of ECMO and MV, but the rate of successfully weaned from ECMO, bleeding, bloodstream infection complications and pump failure were similar. By contrast, oxygenator failure was more frequent in patients receiving VV ECMO. No significant intergroup difference was observed for the hospitalization costs. CONCLUSION These positive findings showed the conferred survival advantage and safety of VV ECMO compared with VA ECMO, suggesting that VV ECMO may be an effective initial treatment for patients with infection-associated severe PARDS.
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Affiliation(s)
- Yun Cui
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Jiaying Dou
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyi Shi
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Zhe Zhao
- Pediatric Intensive Care Unit, Senior Department of Pediatrics, The Seventh Medical Center of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhen Zhang
- Pediatric Intensive Care Unit, First Hospital of Jilin University, Changchun, China
| | - Yingfu Chen
- Critical Care Medicine, Children's Hospital Affiliated to Chongqing Medical University, Chongqing, China
| | - Chao Cheng
- Pediatric Intensive Care Unit, Shengjing Hospital Affiliated to China Medical University, Shenyang, China
| | - Desheng Zhu
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, China
| | - Xueli Quan
- Surgical Intensive Care Unit of Henan Children's Hospital, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Xuemei Zhu
- Critical Care Medicine, Children's Hospital Affiliated to Fudan University, Shanghai, China
| | - Wenyan Huang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Lillie J, Pienaar A, Budd J, Speggiorin S, Gordon A, James P, Perkins J, Griffiths B, Fine-Goulden M, Austin C, Salih C, Agnew N, Nyman AG. Multisite Veno-Venous Cannulation for Neonates and Nonambulatory Children. Pediatr Crit Care Med 2021; 22:692-700. [PMID: 33950887 DOI: 10.1097/pcc.0000000000002753] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Neonates with respiratory failure are ideally supported with veno-venous rather than veno-arterial extracorporeal membrane oxygenation due to the reduced rate of neurologic complications. However, the proportion of neonates supported with veno-venous extracorporeal membrane oxygenation is declining. We report multisite veno-venous extracorporeal membrane oxygenation, accessing the neck, returning to the inferior vena cava via the common femoral vein in neonates and children less than 10 kg. DESIGN Retrospective case series with 1 year minimum follow-up. PATIENTS Patients less than 10 kg supported with veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein. SETTING A 30-bed pediatric intensive care delivering extracorporeal membrane oxygenation to approximately 20 children annually. INTERVENTIONS Veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein was delivered using two single lumen cannulae. MEASUREMENTS AND MAIN RESULTS January 2015 to August 2019, 11 patients underwent veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein with median weight of 3.6 kg (interquartile range 2.8-6.1 kg), and median corrected gestational age of 13 days (interquartile range, 2-175 d). The smallest patient weighed 2.1 kg. Seven patients had comorbidities. Extracorporeal membrane oxygenation was technically successful in all patients with median flows of 126 mL/kg/min (interquartile range, 120-138 mL/kg/min) and median arterial oxygenation saturation of 94% (interquartile range, 91-98%) at 24 hours. Nine survived to home discharge, and two were palliated. Common femoral vein occlusion was observed in all patients on ultrasound post decannulation. There was no clinical or functional deficit in the cannulated limb at follow-up, a minimum of 1 year post extracorporeal membrane oxygenation. CONCLUSIONS Veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein was performed safely in patients under 10 kg with the smallest patient weighing 2.1 kg. Although occlusion of the common femoral vein was observed in patients post decannulation, subsequent follow-up demonstrated no clinical implications. We challenge current practice that veno-venous extracorporeal membrane oxygenation accessing the jugular and returning to the femoral vein cannot be performed in nonambulatory patients and suggest that this strategy is preferred over veno-arterial extracorporeal membrane oxygenation in infants requiring extracorporeal membrane oxygenation for respiratory failure.
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Affiliation(s)
- Jon Lillie
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
| | - Alison Pienaar
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
| | - Jenny Budd
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
| | - Simone Speggiorin
- Department of Cardiothoracic Surgery, Evelina London Children's Hospital, London, United Kingdom
| | - Anne Gordon
- Department of Paediatric Neuroscience, Faculty of population health King's College London, Evelina London Children's Hospital, London, United Kingdom
| | - Paul James
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
| | - Jo Perkins
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
| | - Benedict Griffiths
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
| | - Miriam Fine-Goulden
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
| | - Conal Austin
- Department of Cardiothoracic Surgery, Evelina London Children's Hospital, London, United Kingdom
| | - Caner Salih
- Department of Cardiothoracic Surgery, Evelina London Children's Hospital, London, United Kingdom
| | - Nicola Agnew
- Department of Perfusion Department, Evelina London Children's Hospital, London, United Kingdom
| | - Andrew G Nyman
- Department of Paediatric Intensive Care, Evelina London Children's Hospital, London, United Kingdom
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