Natural Course of Cholestasis in Neonates on Extracorporeal Membrane Oxygenation (ECMO): 10-Year Experience at a Single Institution

Optimizing Outcomes in Extracorporeal Membrane Oxygenation Postcardiotomy in Pediatric Population

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.

Nutrition adequacy, gastrointestinal and hepatic function during extracorporeal membrane oxygenation in critically ill adults: a retrospective observational study

AIMS

To identify clinical and biochemical markers associated with nutrition adequacy and gastrointestinal and liver dysfunction in adults on extracorporeal membrane oxygenation (ECMO).

METHODS

A retrospective, observational, study was conducted at 2 centres in Australia. Adult patients who received ECMO from July 2011 to June 2015 were included. Mode of ECMO used, fluid balance, number of systemic inflammatory response syndrome (SIRS) criteria present, vasoactive-inotropic scores (VIS) and liver function tests (LFTs) were collected for the duration of ECMO until 7 days after ECMO cessation. Multiple regression models were used to determine if the collected variables were associated with nutrition adequacy. The mean LFTs during ECMO were also compared to mean LFTs post ECMO cessation.

RESULTS

During the first 5 days of ECMO commencement, mean nutrition adequacy was 10% higher in the veno-venous (VV) ECMO group than in the veno-arterial (VA) group (95% confidence interval [CI], 2% to 17%). For every 5,000 ml increase of fluid balance, an associated decrease in nutrition adequacy was observed (-8%, 95% CI, -15% to -2%). A doubling of bilirubin and VIS were associated with a mean reduction in nutrition adequacy of -5% (CI -8% to -2%) and -2% (CI, -3% to -1%), respectively.

CONCLUSIONS

In the first 5 days of ECMO commencement, higher nutrition adequacy was associated with the VV mode of ECMO and reduced nutrition adequacy with increased fluid balance, more vasopressor and inotropic support and raised bilirubin. Prospective investigation is required to confirm whether these associations have a causal relationship.

Clinical Implications for Children Developing Direct Hyperbilirubinemia on Extracorporeal Membrane Oxygenation

OBJECTIVE

Extracorporeal membrane oxygenation (ECMO)-associated direct hyperbilirubinemia (DHB) is likely multifactorial. The objective of this study is to assess the frequency and risk factors for developing direct hyperbilirubinemia while on ECMO, and its implication on the mortality of children.

METHODS

We performed a retrospective study between January 2010 and January 2020. Using Mayo Clinic electronic health record, we identified children (<18 years) who required veno-arterial (VA) ECMO support. Demographics, ECMO indication, laboratory findings, and outcomes were abstracted. Illness acuity scores, including vasoactive-ionotropic score (VIS), were used to assess disease severity at time of admission. Study cohort was divided into two groups: children who developed direct hyperbilirubinemia (DHB) on ECMO and children who did not (control). DHB was defined as direct bilirubin (DB) of >1.0 mg/dL. Disease acuity and mortality rates were compared between the two groups. Logistic regression was used to analyze the risk of mortality independent of potential confounding variables.

RESULTS

We identified 106 children who required ECMO support during the study period. Of those, 36 (34%) children developed DHB on ECMO. Illness acuity scores were significantly higher in the DHB group on ECMO day 2 (P = 0.046) and day 7 (P = 0.01). Mortality rate was higher in the DHB group 72%, versus 29% in the control group (P < 0.001).

CONCLUSION

DHB was associated with a higher mortality rate than the control group.

The evolving role of ECMO in liver transplantation

PURPOSE OF REVIEW

To review the indications for extra-corporeal membrane oxygenation (ECMO) in liver transplantation (LT) recipients and their optimal management on ECMO.

RECENT FINDINGS

Recent studies have reported a 30-40% survival rate among LT recipients that receive ECMO. Increasingly, case reports have documented successful outcomes of LT performed for patients on preoperative ECMO. Outcomes appear to be superior with patients in the immediate peri-LT period with reversible causes of severe, acute respiratory, and/or cardiovascular collapse. Mortality is most commonly secondary to infection. Volume optimization with CRRT may improve outcomes and perfusion to the graft, especially for patients on veno-arterial ECMO. There is little consensus on management of anticoagulation in these patients, but it can likely be held temporarily when the patient is coagulopathic and/or experiencing bleeding complications.

SUMMARY

ECMO should be considered in the peri-LT period for patients with severe, acute, and reversible causes of respiratory and/or cardiovascular collapse, with acceptable outcomes in patients that would otherwise not be expected to survive. Management of the post-LT patient on ECMO is challenging with a slowly enlarging body of literature to inform decision making.

Hemolysis During Pediatric Extracorporeal Membrane Oxygenation: Associations With Circuitry, Complications, and Mortality

OBJECTIVES

To describe factors associated with hemolysis during pediatric extracorporeal membrane oxygenation and the relationships between hemolysis, complications, and mortality.

DESIGN

Secondary analysis of data collected prospectively by the Collaborative Pediatric Critical Care Research Network between December 2012 and September 2014.

SETTING

Three Collaborative Pediatric Critical Care Research Network-affiliated hospitals.

PATIENTS

Age less than 19 years and treated with extracorporeal membrane oxygenation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Hemolysis was defined based on peak plasma free hemoglobin levels during extracorporeal membrane oxygenation and categorized as none (< 0.001 g/L), mild (0.001 to < 0.5 g/L), moderate (0.5 to < 1.0 g/L), or severe (≥ 1.0 g/L). Of 216 patients, four (1.9%) had no hemolysis, 67 (31.0%) had mild, 51 (23.6%) had moderate, and 94 (43.5%) had severe. On multivariable analysis, variables independently associated with higher daily plasma free hemoglobin concentration included the use of in-line hemofiltration or other continuous renal replacement therapy, higher hemoglobin concentration, higher total bilirubin concentration, lower mean heparin infusion dose, lower body weight, and lower platelet count. Using multivariable Cox modeling, daily plasma free hemoglobin was independently associated with development of renal failure during extracorporeal membrane oxygenation (defined as creatinine > 2 mg/dL [> 176.8 μmol/L] or use of in-line hemofiltration or continuous renal replacement therapy) (hazard ratio, 1.04; 95% CI, 1.02-1.06; p < 0.001), but not mortality (hazard ratio, 1.01; 95% CI, 0.99-1.04; p = 0.389).

CONCLUSIONS

Hemolysis is common during pediatric extracorporeal membrane oxygenation. Hemolysis may contribute to the development of renal failure, and therapies used to manage renal failure such as in-line hemofiltration and other forms of continuous renal replacement therapy may contribute to hemolysis. Hemolysis was not associated with mortality after controlling for other factors. Monitoring for hemolysis should be a routine part of extracorporeal membrane oxygenation practice, and efforts to reduce hemolysis may improve patient care.

Incidence of general surgical procedures in adult patients on extracorporeal membrane oxygenation

Purpose

Extracorporeal membrane oxygenation use may predispose patients to developing conditions that require either consultation with a general surgeon or a general surgical procedure. We aimed to evaluate the incidence and outcomes of adult extracorporeal membrane oxygenation patients who underwent general surgical procedure.

Methods

This was a single institution retrospective study of adult extracorporeal membrane oxygenation patients from 2012 to 2015. Outcomes were compared between patients who underwent general surgical procedure with those that did not.

Results

Of the 115 patients, 54 (46.9%) required a general surgeon while 42 (36.5%) required a general surgical procedure. No significant differences were observed in mortality (35.7% vs. 46.6%; p = 0.256) and extracorporeal membrane oxygenation-related complications (45.7% vs. 32.5%; p = 0.175). Patients with general surgical procedure had longer extracorporeal membrane oxygenation duration (13 vs. 5 days; p < 0.0001), longer length of stay (36 vs. 15 days; p = 0.0005), more wound infections (19.05% vs. 5.5%; p = 0.029), more urinary tract infections (38.1% vs. 10.96%; p = 0.0006), and more pulmonary emboli (19.05% vs. 5.48%; p = 0.029). In general surgical procedure patients, no difference in bleeding complications was observed regardless of anti-coagulation status (29.4% vs. 16%; p = 0.44).

Conclusion

Common general surgical procedures are safe and feasible in adult extracorporeal membrane oxygenation patients. Duration of extracorporeal membrane oxygenation was longer for patients requiring general surgical procedure. Despite the common use of anticoagulants, there was no increase in bleeding events in general surgical procedure patients.

Rare causes of hyperbilirubinemia after lung transplantation: our experience at a single center

Background

Lung transplantation is the last treatment option for end-stage lung disease, and the number of lung transplantations has been steadily increasing. Hyperbilirubinemia is a rare complication after lung transplantation. The aim of this study was to review rare causes of hyperbilirubinemia after lung transplantation at our center.

Methods

In this single-center study, we retrospectively reviewed the records of 116 consecutive lung transplantation patients who underwent lung transplantation at Severance Hospital and Gangnam Severance Hospital of Yonsei University College of Medicine in South Korea between December 22, 2010 and January 1, 2016. Hyperbilirubinemia was defined as a total bilirubin level exceeding 5 mg/dL for at least 3 days after lung transplantation.

Results

Hyperbilirubinemia occurred in 33 patients (28.4%) who received lung transplants at our institution. Twenty-four cases involved common causes such as drug toxicity, biliary tract stone, sepsis, and bleeding. However, rare causes of hyperbilirubinemia including hemophagocytic lymphohistiocytosis (HLH), thrombotic microangiopathy (TMA), and ischemic cholangiopathy were observed in 9 (7.8%) patients during the study period. All patients with hyperbilirubinemia due to a rare cause died despite aggressive treatment.

Conclusion

Causes of hyperbilirubinemia after lung transplantation are varied, and the prognosis of patients with hyperbilirubinemia arising from rare causes was poor. Therefore, early evaluation and management of hyperbilirubinemia after lung transplantation is important to improve patient outcomes.

Utility of measuring direct bilirubin at first 72 h of age in neonates admitted to the neonatal intensive care unit

OBJECTIVE

To assess the utility of measuring direct bilirubin (DB) during the first 72 h of life in infants admitted to the neonatal intensive care unit (NICU).

STUDY DESIGN

Infants born between May 2006 and June 2013, and admitted to the NICU were included. Abnormal DB was defined as: DB level⩾1 mg dl^-1 with a corresponding TB of ⩽5 mg dl^-1 or DB level >20% of the corresponding TB>5 mg dl^-1.

RESULTS

The DB levels were measured in 3715 infants during the first 72 h of life. Sixty-three infants (1.7%) had abnormal DB. In a number of infants with potentially treatable diseases (biliary atresia and choledochal cyst), the only abnormal finding was a mildly elevated DB (1 to 2 mg dl^-1) during the first 3 days of life. In 22 infants (35%), the cause for high DB was unknown (16%) or not investigated (19%).

CONCLUSIONS

Routine measurement of DB in neonates admitted to NICU may be helpful in identifying potentially treatable causes of cholestasis.

Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure: an evidence-based review of the past decade (2002-2012)

OBJECTIVE

To provide a comprehensive evidence-based review of extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure.

DATA SOURCE

A thorough computerized bibliographic search of the clinical literature regarding the use of extracorporeal membrane oxygenation in the neonatal and pediatric populations.

STUDY SELECTION

Clinical trials published between January 1, 2002, and October 1, 2012, including "extracorporeal membrane oxygenation" or "ECMO" and limited to studies involving humans aged 0-18 years. Trials focused on extracorporeal membrane oxygenation for cardiac indications were excluded from this study, unless the study was evaluating ancillary therapies in conjunction with extracorporeal membrane oxygenation.

DATA EXTRACTION

Studies were evaluated for inclusion based on reporting of patient outcomes and/or strategic considerations, such as cannulation strategies, timing of extracorporeal membrane oxygenation utilization, and ancillary therapies.

DATA SYNTHESIS

Pertinent data are summarized, and the available data are objectively classified based on the value of the study design from which the data are obtained.

CONCLUSIONS

Despite a large number of published extracorporeal membrane oxygenation studies, there remains a paucity of high-quality clinical trials. The available data support continued use of extracorporeal membrane oxygenation for respiratory failure refractory to conventional therapy for neonatal and pediatric patients without significant comorbidities. Further research is needed to better quantify the benefit of extracorporeal membrane oxygenation and the utility of many therapies commonly applied to extracorporeal membrane oxygenation patients.

Outcomes of neonates undergoing extracorporeal membrane oxygenation support using centrifugal versus roller blood pumps

BACKGROUND

Advances in centrifugal blood pump technology have led to increased use of centrifugal pumps in extracorporeal membrane oxygenation (ECMO) circuits. Their efficacy and safety in critically ill neonates remains unknown. Blood cell trauma leading to hemolysis may result in end-organ injury in critically ill neonates receiving centrifugal pump ECMO. We hypothesized that neonates undergoing ECMO support using centrifugal pumps were at increased odds of hemolysis and subsequent end-organ injury.

METHODS

Children 30 days of age or younger who received support with venoarterial ECMO and were reported to the Extracorporeal Life Support Registry during 2007 to 2009 underwent propensity score matching (Greedy matching 1:1) using pre-ECMO support characteristics.

RESULTS

A total of 1,592 neonates receiving ECMO (centrifugal pump = 163 and roller pump = 1,492) were identified. Significant differences in demographic, presupport, and cannulation variables were present before matching. One hundred seventy-six neonates who were supported using either centrifugal (n = 88) or roller pumps (n = 88) were matched using propensity scoring. No significant differences in demographic, presupport, or cannulation variables were present after matching. Neonates undergoing support using centrifugal pumps had increased odds of hemolysis (odds ratio [OR], 7.7 [2.8-21.2]), hyperbilirubinemia (OR, 20.8 [2.7-160.4]), hypertension (OR, 3.2 [1.3-8.0]), and acute renal failure (OR, 2.4 [1.1-5.6]). Survival to discharge was not different between pump types.

CONCLUSIONS

Use of ECMO using centrifugal pumps is associated with increased odds of hemolysis that likely contributes to other end-organ injury. Research into the optimal use of centrifugal pumps and strategies to prevent support-related complications need to be investigated.

Novel observations during extracorporeal membrane oxygenation in patients with ARDS due to the H1N1 pandemic influenza

We report four patients with novel observations during extracorporeal membrane oxygenation support (ECMO). ECMO was initiated because of severe ARDS due to the primary H1N1 pandemic influenza pneumonia. Two patients had excessive conjugated hyperbilirubinemia and two had unproportional depletion of the coagulation factor IX. Pathogenetic mechanisms and clinical relevance of the noticed phenomena are discussed.