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Siddiqui K, Hafeez MU, Ahmad A, Kazmi SO, Chatterjee S, Bershad E, Hirzallah M, Rao C, Damani R. Multimodal Neurologic Monitoring in Patients Undergoing Extracorporeal Membrane Oxygenation. Cureus 2024; 16:e59476. [PMID: 38826870 PMCID: PMC11140437 DOI: 10.7759/cureus.59476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/30/2024] [Indexed: 06/04/2024] Open
Abstract
Introduction Extracorporeal membrane oxygenation (ECMO) is associated with a high rate of neurologic complications. Multimodal neurologic monitoring (MNM) has the potential for early detection and intervention. We examined the safety and feasibility of noninvasive MNM during ECMO. We hypothesized that survivors and non-survivors would have meaningful differences in transcranial Doppler (TCD) sonography and electroencephalographic (EEG) characteristics, which we aimed to identify. We also investigated adverse neurologic events and attempted to identify differences in EEG and TCD characteristics among patients based on the type of ECMO and the occurrence of these events. Material and methods We performed an observational study on all patients undergoing ECMO at Baylor St. Luke's Medical Center's critical care unit in Houston, Texas, United States, from January 2017 to February 2019. All patients underwent a noninvasive MNM protocol. Results NM was completed in 75% of patients; all patients received at least one component of the monitoring protocol. No adverse events were noted, showing the feasibility and safety of the protocol. The 60.4% of patients who did not survive tended to be older, had lower ejection fractions, and had lower median right middle cerebral artery (MCA) pulsatility and resistivity indexes. Patients undergoing venoarterial (VA)-ECMO had lower median left and right MCA velocities and lower right Lindegaard ratios than patients who underwent venovenous-ECMO. In VA-ECMO patients, EEG less often showed sleep architecture, while other findings were similar between groups. Adverse neurologic events occurred in 24.7% of patients, all undergoing VA-ECMO. Acute ischemic stroke occurred in 22% of patients, intraparenchymal hemorrhage in 4.9%, hypoxic-ischemic encephalopathy in 3.7%, subarachnoid hemorrhage in 2.5%, and subdural hematoma in 1.2%. Conclusion Our results suggest that MNM is safe and feasible for patients undergoing ECMO. Certain EEG and TCD findings could aid in the early detection of neurologic deterioration. MNM may not just be used in monitoring patients undergoing ECMO but also in prognostication and aiding clinical decision-making.
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Affiliation(s)
| | | | - Ali Ahmad
- Neurology, Baylor College of Medicine, Houston, USA
| | - Syed O Kazmi
- Neurology, Salem Health Hospitals & Clinics, Salem, USA
| | | | - Eric Bershad
- Neurology, Baylor College of Medicine, Houston, USA
| | | | - Chethan Rao
- Neurocritical Care, Baylor College of Medicine, Houston, USA
| | - Rahul Damani
- Neurology, Baylor College of Medicine, Houston, USA
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Chalia M, Singh D, Boyd SG, Hannam S, Hoskote A, Pressler R. Neonatal seizures during extra corporeal membrane oxygenation support. Eur J Pediatr 2024:10.1007/s00431-024-05510-w. [PMID: 38488877 DOI: 10.1007/s00431-024-05510-w] [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: 01/26/2024] [Revised: 02/28/2024] [Accepted: 03/02/2024] [Indexed: 03/17/2024]
Abstract
To evaluate EEG monitoring during neonatal ECMO and to identify any correlations between seizure detection to abnormal neuroimaging. Eight-year, service evaluation of neonates who received at least one continuous EEG (cEEG) whilst on ECMO at Great Ormond Street Hospital. Pearson's chi-square test and multivariate logistic regression analysis were used to assess clinical and EEG variables association with seizures and neuroimaging findings. Fifty-seven neonates were studied; 57 cEEG recordings were reviewed. The incidence of seizures was 33% (19/57); of these 74% (14/19) were electrographic-only. The incidence of status epilepticus was 42%, (8/19 with 6 neonates having electrographic-only status and 2 electro-clinical status. Seizures were detected within an hour of recording in 84%, (16/19). The overall mortality rate was 39% (22/57). Seizure detection was strongly associated with female gender (OR 4.8, 95% CI: 1.1-20.4, p = 0.03), abnormal EEG background activity (OR 2.8, 95% CI: 1.1-7.4, p = 0.03) and abnormal EEG focal features (OR 23.6, 95% CI: 5.4-103.9, p = 0.001). There was a strong association between the presence of seizures and abnormal neuroimaging findings (OR 10.9, 95% CI: 2.8-41.9, p = 0.001). Neonates were highly likely to have abnormal neuroimaging findings in the presence of severely abnormal background EEG (OR 9.5, 95% CI 1.7-52.02, p = 0.01) and focal EEG abnormalities (OR 6.35, 95% CI 1.97-20.5, p = 0.002)Conclusion: The study highlights the importance of cEEG in neonates undergoing ECMO. An association between seizure detection and abnormal neuroimaging findings was described. What is Known: • Patients on ECMO are at a higher risk of seiures. • Continuous EEG monitoring is recommended by the ACNS for high risk and ECMO patients. What is New: • In this cohort, neonates with sezirues were 11 times more likely of having abnromal neuroimaging findings. • Neonates with burst suppressed or suppressed EEG background were 9.5 times more likely to have abnormal neuroimaging findings. What does this study add? • This study reports a 33% incidence of neonatal seizures during ECMO. • Neonates with seizures were 11 times more likely to have an abnormal brain scan. • The study captures the real-time approach of EEG monitoring. • Recommended cEEG monitoring should last at least 24 h for ECMO patients. • This is the first study to assess this in neonates only.
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Affiliation(s)
- Maria Chalia
- Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK.
| | - Davinder Singh
- Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children, London, UK
| | - Stewart G Boyd
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK
| | - Simon Hannam
- Neonatal Intensive Care Unit, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK
| | - Aparna Hoskote
- Cardiac Intensive Care Unit, Great Ormond Street Hospital for Children, London, UK
| | - Ronit Pressler
- Department of Clinical Neurophysiology, Great Ormond Street Hospital for Children, Great Ormond Street, London, WC1N 3JH, UK
- Clinical Neuroscience, University College London, UCL, Great Ormond Street Institute of Child Health, London, UK
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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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Pandiyan P, Cvetkovic M, Antonini MV, Shappley RKH, Karmakar SA, Raman L. Clinical Guidelines for Routine Neuromonitoring in Neonatal and Pediatric Patients Supported on Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:895-900. [PMID: 37603797 DOI: 10.1097/mat.0000000000001896] [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: 08/23/2023] Open
Abstract
DISCLAIMER These guidelines for routine neuromonitoring in neonatal and pediatric patients supported on extracorporeal membrane oxygenation (ECMO) are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/ECMO and describe what are believed to be useful and safe practice for ECLS and ECMO but these are not necessarily consensus recommendations. The aim of clinical guidelines was to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or being deemed inclusive of all proper methods of care nor exclusive of other methods of care directed at obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient considering all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
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Affiliation(s)
- Poornima Pandiyan
- From the Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Tufts University School of Medicine, Boston, Massachusetts
| | - Mirjana Cvetkovic
- Cardiac Critical Care Division, Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital - AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
| | - Rebekah K H Shappley
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Swati A Karmakar
- Department of Pediatrics, Baylor College of Medicine, Neurology and Developmental Neuroscience Section, Texas Children's Hospital, Houston, Texas
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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Deng B, Ying J, Mu D. Subtypes and Mechanistic Advances of Extracorporeal Membrane Oxygenation-Related Acute Brain Injury. Brain Sci 2023; 13:1165. [PMID: 37626521 PMCID: PMC10452596 DOI: 10.3390/brainsci13081165] [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: 07/10/2023] [Revised: 07/31/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a frequently used mechanical cardiopulmonary support for rescuing critically ill patients for whom conventional medical therapies have failed. However, ECMO is associated with several complications, such as acute kidney injury, hemorrhage, thromboembolism, and acute brain injury (ABI). Among these, ABI, particularly intracranial hemorrhage (ICH) and infarction, is recognized as the primary cause of mortality during ECMO support. Furthermore, survivors often suffer significant long-term morbidities, including neurocognitive impairments, motor disturbances, and behavioral problems. This review provides a comprehensive overview of the different subtypes of ECMO-related ABI and the updated advance mechanisms, which could be helpful for the early diagnosis and potential neuromonitoring of ECMO-related ABI.
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Affiliation(s)
- Bixin Deng
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
| | - Junjie Ying
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
| | - Dezhi Mu
- Department of Pediatrics, West China Second University Hospital, Sichuan University, Chengdu 610041, China;
- Key Laboratory of Birth Defects and Related Diseases of Women and Children, Sichuan University, Ministry of Education, Chengdu 610041, China;
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Callier K, Dantes G, Johnson K, Linden AF. Pediatric ECLS Neurologic Management and Outcomes. Semin Pediatr Surg 2023; 32:151331. [PMID: 37944407 DOI: 10.1016/j.sempedsurg.2023.151331] [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: 11/12/2023]
Abstract
Neurologic complications associated with extracorporeal life support (ECLS), including seizures, ischemia/infarction, and intracranial hemorrhage significantly increase morbidity and mortality in pediatric and neonatal patients. Prompt recognition of adverse neurologic events may provide a window to intervene with neuroprotective measures. Many neuromonitoring modalities are available with varying benefits and limitations. Several pre-ECLS and ECLS-related factors have been associated with an increased risk for neurologic complications. These may be patient- or circuit-related and include modifiable and non-modifiable factors. ECLS survivors are at risk for long-term neurological sequelae affecting neurodevelopmental outcomes. Possible long-term outcomes range from normal development to severe impairment. Patients should undergo a neurological evaluation prior to discharge, and neurodevelopmental assessments should be included in each patient's structured, multidisciplinary follow-up. Safe pediatric and neonatal ECLS management requires a thorough understanding of neurological complications, neuromonitoring techniques and limitations, considerations to minimize risk, and an awareness of possible long-term ramifications. With a focus on ECLS for respiratory failure, this manuscript provides a review of these topics and summarizes best practice guidelines from international organizations and expert consensus.
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Affiliation(s)
- Kylie Callier
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Goeto Dantes
- Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Kevin Johnson
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Allison F Linden
- Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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7
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Chahine A, Chenouard A, Joram N, Berthomieu L, Du Pont-Thibodeau G, Leclere B, Liet JM, Maminirina P, Leclair-Visonneau L, Breinig S, Bourgoin P. Continuous Amplitude-Integrated Electroencephalography During Neonatal and Pediatric Extracorporeal Membrane Oxygenation. J Clin Neurophysiol 2023; 40:317-324. [PMID: 34387276 DOI: 10.1097/wnp.0000000000000890] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
PURPOSE Early prognostication of neurologic outcome in neonates and children supported with extra-corporeal membrane oxygenation (ECMO) is challenging. Amplitude-integrated EEG (aEEG) offers the advantages of continuous monitoring and 24-hours availability at the bedside for intensive care unit providers. The objective of this study was to describe the early electrophysiological background patterns of neonates and children undergoing ECMO and their association with neurologic outcomes. METHODS This was a retrospective review of neonates and children undergoing ECMO and monitored with aEEG. Amplitude-integrated EEG was summarized as an aEEG background score determined within the first 24 hours of ECMO and divided in 3-hour periods. Screening for electrical seizures was performed throughout the full ECMO duration. Neurologic outcome was defined by the Pediatric Cerebral Performance Category score at hospital discharge. RESULTS Seventy-three patients (median age 79 days [8-660], median weight 4.78 kg [3.24-10.02]) were included in the analysis. Thirty-two patients had a favorable neurologic outcome and 41 had an unfavorable neurologic outcome group at hospital discharge. A 24-hour aEEG background score >17 was associated with an unfavorable outcome with a sensitivity of 44%, a specificity of 97%, a positive predictive value of 95%, and a negative predictive value of 57%. In multivariate analysis, 24-hour aEEG background score was associated with unfavorable outcome (hazard ratio, 6.1; p = 0.001; 95% confidence interval, 2.31-16.24). The presence of seizures was not associated with neurologic outcome at hospital discharge. CONCLUSIONS Continuous aEEG provides accurate neurologic prognostication in neonates and children supported with ECMO. Early aEEG monitoring may help intensive care unit providers to guide clinical care and family counseling.
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Affiliation(s)
- Adela Chahine
- Pediatric Intensive Care Unit, University Hospital, Toulouse, France
| | - Alexis Chenouard
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | - Nicolas Joram
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | - Lionel Berthomieu
- Pediatric Intensive Care Unit, University Hospital, Toulouse, France
| | | | - Brice Leclere
- Department of Medical Evaluation and Epidemiology, Nantes University Hospital, Nantes, France
| | - Jean-Michel Liet
- Pediatric Intensive Care Unit, University Hospital, Nantes, France
| | | | | | - Sophie Breinig
- Pediatric Intensive Care Unit, University Hospital, Toulouse, France
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit and Pediatric Cardiac Anesthesia, University Hospital, Nantes, France
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8
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Cvetkovic M, Chiarini G, Belliato M, Delnoij T, Zanatta P, Taccone FS, Miranda DDR, Davidson M, Matta N, Davis C, IJsselstijn H, Schmidt M, Broman LM, Donker DW, Vlasselaers D, David P, Di Nardo M, Muellenbach RM, Mueller T, Barrett NA, Lorusso R, Belohlavek J, Hoskote A. International survey of neuromonitoring and neurodevelopmental outcome in children and adults supported on extracorporeal membrane oxygenation in Europe. Perfusion 2023; 38:245-260. [PMID: 34550013 DOI: 10.1177/02676591211042563] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND Adverse neurological events during extracorporeal membrane oxygenation (ECMO) are common and may be associated with devastating consequences. Close monitoring, early identification and prompt intervention can mitigate early and late neurological morbidity. Neuromonitoring and neurocognitive/neurodevelopmental follow-up are critically important to optimize outcomes in both adults and children. OBJECTIVE To assess current practice of neuromonitoring during ECMO and neurocognitive/neurodevelopmental follow-up after ECMO across Europe and to inform the development of neuromonitoring and follow-up guidelines. METHODS The EuroELSO Neurological Monitoring and Outcome Working Group conducted an electronic, web-based, multi-institutional, multinational survey in Europe. RESULTS Of the 211 European ECMO centres (including non-ELSO centres) identified and approached in 23 countries, 133 (63%) responded. Of these, 43% reported routine neuromonitoring during ECMO for all patients, 35% indicated selective use, and 22% practiced bedside clinical examination alone. The reported neuromonitoring modalities were NIRS (n = 88, 66.2%), electroencephalography (n = 52, 39.1%), transcranial Doppler (n = 38, 28.5%) and brain injury biomarkers (n = 33, 24.8%). Paediatric centres (67%) reported using cranial ultrasound, though the frequency of monitoring varied widely. Before hospital discharge following ECMO, 50 (37.6%) reported routine neurological assessment and 22 (16.5%) routinely performed neuroimaging with more paediatric centres offering neurological assessment (65%) as compared to adult centres (20%). Only 15 (11.2%) had a structured longitudinal follow-up pathway (defined followup at regular intervals), while 99 (74.4%) had no follow-up programme. The majority (n = 96, 72.2%) agreed that there should be a longitudinal structured follow-up for ECMO survivors. CONCLUSIONS This survey demonstrated significant variability in the use of different neuromonitoring modalities during and after ECMO. The perceived importance of neuromonitoring and follow-up was noted to be very high with agreement for a longitudinal structured follow-up programme, particularly in paediatric patients. Scientific society endorsed guidelines and minimum standards should be developed to inform local protocols.
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Affiliation(s)
- Mirjana Cvetkovic
- Cardiac Intensive Care and ECMO, Great Ormond Street Hospital for Children NHS Foundation Trust & UCL Great Ormond Street Institute of Child Health, London, UK
| | - Giovanni Chiarini
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,2nd Intensive Care Unit, Spedali Civili, University of Brescia, Brescia, Italy
| | - Mirko Belliato
- Second Anaesthesia and Intensive Care Unit, S. Matteo Hospital, IRCCS, Pavia, Italy
| | - Thijs Delnoij
- Department of Cardiology and Department of Intensive Care Unit, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Paolo Zanatta
- Anaesthesia and Multi-Speciality Intensive Care, Integrated University Hospital of Verona, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Université Libre de Bruxelles, Hopital Erasme, Bruxelles, Belgium
| | - Dinis Dos Reis Miranda
- Department of Intensive Care, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Nashwa Matta
- Neonatal Unit, Princess Royal Maternity, Glasgow, Scotland
| | - Carl Davis
- Surgery Unit, Royal Hospital for Children, Glasgow, Scotland
| | - Hanneke IJsselstijn
- Pediatric Surgery and Intensive Care, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Matthieu Schmidt
- Sorbonne Université, INSERM UMRS_1166-iCAN, Institute of Cardiometabolism and Nutrition, Assistance Publique-Hôpitaux de Paris, Pitié-Salpêtrière Hospital, Medical Intensive Care Unit, Paris, France
| | - Lars Mikael Broman
- ECMO Centre Karolinska, Department of Pediatric Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Dirk W Donker
- Intensive Care Center, University Medical Centre, Utrecht, The Netherlands
| | - Dirk Vlasselaers
- Department Intensive Care Medicine, University Hospital Leuven, Leuven, Belgium
| | - Piero David
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Matteo Di Nardo
- Paediatric Intensive Care, Bambino Gesù Children's Hospital, Rome, Italy
| | - Ralf M Muellenbach
- Department of Anaesthesia and Intensive Care, Klinikum Kassel GmbH, Kassel, Germany
| | | | - Nicholas A Barrett
- Department of Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Jan Belohlavek
- 2nd Department of Internal Medicine, Cardiovascular Medicine, General Teaching Hospital and 1st Medical School, Charles University in Prague, Praha, Czech Republic
| | - Aparna Hoskote
- Cardiac Intensive Care and ECMO, Great Ormond Street Hospital for Children NHS Foundation Trust & UCL Great Ormond Street Institute of Child Health, London, UK
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9
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Bourgoin P, Lecomte J, Oualha M, Berthomieu L, Pereira T, Davril E, Lamoureux F, Joram N, Chenouard A, Duflot T. Population Pharmacokinetics of Levosimendan and its Metabolites in Critically Ill Neonates and Children Supported or Not by Extracorporeal Membrane Oxygenation. Clin Pharmacokinet 2023; 62:335-348. [PMID: 36631687 DOI: 10.1007/s40262-022-01199-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/11/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Levosimendan (LVSMD) is a calcium-sensitizer inotropic and vasodilator agent whose use might have a beneficial effect on the weaning of venoarterial extracorporeal membrane oxygenation (VA-ECMO). In light of LVSMD pharmacological characteristics, we hypothesized that ECMO may induce major pharmacokinetic (PK) modifications for LVSMD and its metabolites. OBJECTIVE The aim of this study was to investigate the PK of LVSMD and its metabolites, and to assess the effects of ECMO on PK parameters. METHODS We conducted a multicentric, prospective study (NCT03681379). Twenty-seven infusions of LVSMD were performed, allowing for the collection of 255 blood samples. Non-linear mixed-effects modeling software (MONOLIX®) was used to develop a parent-metabolite PK model of LVSMD and its metabolites. RESULTS Most patients received a 0.2 µg/kg/min infusion of LVSMD over 24 h. After elimination of non-reliable samples or concentrations below the limit of quantification, 166, 101 and 85 samples were considered for LVSMD, OR-1855 and OR-1896, respectively, of which 81, 53 and 41, respectively, were drawn under ECMO conditions. Parent-metabolite PK modeling revealed that a two-compartment model with first-order elimination best described LVSMD PK. Use of a transit compartment allowed for an explanation of the delayed appearance of circulating OR-1855 and OR-1896, with the latter following a first-order elimination. Patient weight influenced the central volume of distribution and elimination of LVSMD. ECMO support increased the elimination rate of LVSMD by 78%, and ECMO also slowed down the metabolite formation rate by 85% for OR-1855, which in turn is converted to the active metabolite OR-1896, 14% slower than without ECMO. Simulated data revealed that standard dosing may not be appropriate for patients under ECMO, with a decrease in the steady-state concentration of LVSMD and lower exposure to the active metabolite OR-1896. CONCLUSIONS ECMO altered PK parameters for LVSMD and its metabolites. An infusion of LVSMD over 48 h, instead of 24 h, with a slightly higher dose may promote synthesis of the active metabolite OR-1896, which is responsible for the long-term efficacy of LVSMD. Further trials evaluating ECMO effects using a PK/pharmacodynamic approach may be of interest. REGISTRATION ClinicalTrials.gov identifier number NCT03681379.
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Affiliation(s)
- Pierre Bourgoin
- Pediatric Intensive Care Unit, CHU Nantes, 44093, Nantes, France. .,Department of Anesthesiology, CHU Nantes, 44093, Nantes, France.
| | - Jules Lecomte
- Department of Anesthesiology, CHU Nantes, 44093, Nantes, France
| | - Mehdi Oualha
- Pediatric Intensive Care Unit, CHU Necker Enfants Malades, 75015, Paris, France
| | - Lionel Berthomieu
- Pediatric Intensive Care Unit, CHU Toulouse, 31059, Toulouse, France
| | - Tony Pereira
- INSERM U1096, UNIROUEN, Normandie University, 76000, Rouen, France
| | - Emeline Davril
- INSERM U1096, UNIROUEN, Normandie University, 76000, Rouen, France
| | - Fabien Lamoureux
- INSERM U1096, UNIROUEN, Normandie University, 76000, Rouen, France.,Department of Pharmacology, CHU Rouen, 76000, Rouen, France
| | - Nicolas Joram
- Pediatric Intensive Care Unit, CHU Nantes, 44093, Nantes, France
| | - Alexis Chenouard
- Pediatric Intensive Care Unit, CHU Nantes, 44093, Nantes, France
| | - Thomas Duflot
- INSERM U1096, UNIROUEN, Normandie University, 76000, Rouen, France.,Department of Pharmacology, CHU Rouen, 76000, Rouen, France.,CHU Rouen, CIC-CRB U1404, 76000, Rouen, France
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10
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Aboul-Nour H, Jumah A, Abdulla H, Sharma A, Howell B, Jayaprakash N, Gardner-Gray J. Neurological monitoring in ECMO patients: current state of practice, challenges and lessons. Acta Neurol Belg 2023; 123:341-350. [PMID: 36701079 PMCID: PMC9878494 DOI: 10.1007/s13760-023-02193-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/16/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) in critically ill patients serves as a management option for end-stage cardiorespiratory failure in medical and surgical conditions. Patients on ECMO are at a high risk of neurologic adverse events including intracranial hemorrhage (ICH), acute ischemic stroke (AIS), seizures, diffuse cerebral edema, and hypoxic brain injury. Standard approaches to neurological monitoring for patients receiving ECMO support can be challenging for multiple reasons, including the severity of critical illness, deep sedation, and/or paralysis. This narrative literature review provides an overview of the current landscape for neurological monitoring in this population. METHODS A literature search using PubMed was used to aid the understanding of the landscape of published literature in the area of neurological monitoring in ECMO patients. RESULTS Review articles, cohort studies, case series, and individual reports were identified. A total of 73 varied manuscripts were summarized and included in this review which presents the challenges and strategies for performing neurological monitoring in this population. CONCLUSION Neurological monitoring in ECMO is an area of interest to many clinicians, however, the literature is limited, heterogenous, and lacks consensus on the best monitoring practices. The evidence for optimal neurological monitoring that could impact clinical decisions and functional outcomes is lacking. Additional studies are needed to identify effective measures of neurological monitoring while on ECMO.
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Affiliation(s)
- Hassan Aboul-Nour
- grid.189967.80000 0001 0941 6502Department of Neurology, Emory University, Atlanta, GA USA ,grid.413103.40000 0001 2160 8953Department of Neurology, Henry Ford Hospital, Detroit, MI USA
| | - Ammar Jumah
- grid.413103.40000 0001 2160 8953Department of Neurology, Henry Ford Hospital, Detroit, MI USA
| | - Hafsa Abdulla
- grid.413103.40000 0001 2160 8953Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA
| | - Amreeta Sharma
- grid.413103.40000 0001 2160 8953Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA
| | - Bradley Howell
- grid.413103.40000 0001 2160 8953Department of Neurology, Henry Ford Hospital, Detroit, MI USA
| | - Namita Jayaprakash
- grid.413103.40000 0001 2160 8953Department of Emergency Medicine, Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA
| | - Jayna Gardner-Gray
- grid.413103.40000 0001 2160 8953Division of Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA ,grid.413103.40000 0001 2160 8953Department of Emergency Medicine, Critical Care Medicine, Henry Ford Hospital, Detroit, MI USA
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11
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Kohne JG, MacLaren G, Shellhaas RA, Benedetti G, Barbaro RP. Variation in electroencephalography and neuroimaging for children receiving extracorporeal membrane oxygenation. Crit Care 2023; 27:23. [PMID: 36650540 PMCID: PMC9847194 DOI: 10.1186/s13054-022-04293-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 12/24/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Seizures, strokes, and intracranial hemorrhage are common and feared complications in children receiving extracorporeal membrane oxygenation (ECMO) support. Researchers and clinicians have proposed and deployed methods for monitoring and detecting neurologic injury, but best practices are unknown. We sought to characterize clinicians' approach to electroencephalography (EEG) and brain imaging modalities in children supported by ECMO. METHODS We performed a retrospective observational cohort study among US Children's Hospitals participating in the Pediatric Health Information System (PHIS) from 2016 to 2021. We identified hospitalizations containing ECMO support. We stratified these admissions by pediatric, neonatal, cardiac surgery, and non-cardiac surgery. We characterized the frequency of EEG, cranial ultrasound, brain computed tomography (CT), magnetic resonance imaging (MRI), and transcranial Doppler during ECMO hospitalizations. We reported key diagnoses (stroke and seizures) and the prescription of antiseizure medication. To assess hospital variation, we created multilevel logistic regression models. RESULTS We identified 8746 ECMO hospitalizations. Nearly all children under 1 year of age (5389/5582) received a cranial ultrasound. Sixty-two percent of the cohort received an EEG, and use increased from 2016 to 2021 (52-72% of hospitalizations). There was marked variation between hospitals in rates of EEG use. Rates of antiseizure medication use (37% of hospitalizations) and seizure diagnoses (20% of hospitalizations) were similar across hospitals, including high and low EEG utilization hospitals. Overall, 37% of the cohort received a CT and 36% received an MRI (46% of neonatal patients). Stroke diagnoses (16% of hospitalizations) were similar between high- and low-MRI utilization hospitals (15% vs 17%, respectively). Transcranial Doppler (TCD) was performed in just 8% of hospitalizations, and 77% of the patients who received a TCD were cared for at one of five centers. CONCLUSIONS In this cohort of children at high risk of neurologic injury, there was significant variation in the approach to EEG and neuroimaging in children on ECMO. Despite the variation in monitoring and imaging, diagnoses of seizures and strokes were similar across hospitals. Future work needs to identify a management strategy that appropriately screens and monitors this high-risk population without overuse of resource-intensive modalities.
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Affiliation(s)
- Joseph G. Kohne
- grid.214458.e0000000086837370Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, USA ,grid.214458.e0000000086837370Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, USA
| | - Graeme MacLaren
- grid.410759.e0000 0004 0451 6143Cardiothoracic Intensive Care Unit, National University Health System, Singapore, Singapore
| | - Renée A. Shellhaas
- grid.214458.e0000000086837370Division of Pediatric Neurology, Department of Pediatrics, University of Michigan, Ann Arbor, USA
| | - Giulia Benedetti
- grid.240741.40000 0000 9026 4165Department of Neurology, Seattle Children’s Hospital and University of Washington, Seattle, USA
| | - Ryan P. Barbaro
- grid.214458.e0000000086837370Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Michigan, Ann Arbor, USA ,grid.214458.e0000000086837370Susan B. Meister Child Health Evaluation and Research Center, University of Michigan School of Medicine, Ann Arbor, USA
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12
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Hoskote A, Hunfeld M, O'Callaghan M, IJsselstijn H. Neonatal ECMO survivors: The late emergence of hidden morbidities - An unmet need for long-term follow-up. Semin Fetal Neonatal Med 2022; 27:101409. [PMID: 36456434 DOI: 10.1016/j.siny.2022.101409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Aparna Hoskote
- Cardiac Intensive Care Unit, Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
| | - Maayke Hunfeld
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, the Netherlands
| | - Maura O'Callaghan
- Cardiac Intensive Care Unit, Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK
| | - Hanneke IJsselstijn
- Intensive Care and Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center Rotterdam, the Netherlands
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13
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Li Q, Shen J, Lv H, Liu Y, Chen Y, Zhou C, Shi J. Incidence, risk factors, and outcomes in electroencephalographic seizures after mechanical circulatory support: A systematic review and meta-analysis. Front Cardiovasc Med 2022; 9:872005. [PMID: 35990978 PMCID: PMC9381842 DOI: 10.3389/fcvm.2022.872005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 07/04/2022] [Indexed: 11/13/2022] Open
Abstract
PurposeTo estimate the overall incidence, risk factors, and clinical outcomes of electroencephalographic (EEG) seizures for adults and children after mechanical circulatory support (MCS).Method and measurementsThis systematic review and meta-analysis were carried out in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidance document. MEDLINE EMBASE and CENTRAL were investigated for relevant studies. The related information was retrieved by two independent reviewers and all analyses were conducted by STATA (version 16.0; Stata Corporation, College Station, TX, United States).ResultSixty studies including 36,191 adult and 55,475 pediatric patients with MCS were enrolled for evaluation. The study showed that the overall incidence of EEG seizures in adults was 2% (95%CI: 1–3%), in which 1% (95%CI: 1–2%) after cardiopulmonary bypass (CPB), and 3% (95%CI: 1–6%) after extracorporeal membrane oxygenation (ECMO). For pediatrics patients, the incidence of EEG seizures was 12% (95%CI: 11–14%), among which 12% (9–15%) after CPB and 13% (11–15%) after ECMO. The major risk factors of EEG seizures after MCS in adults were redo surgery (coefficient = 0.0436, p = 0.044), and COPD (coefficient = 0.0749, p = 0.069). In addition, the gestational week of CPB (coefficient = 0.0544, p = 0.080) and respiratory failure of ECMO (coefficient = –0.262, p = 0.019) were also indicated to be associated with EEG seizures in pediatrics.ConclusionEEG seizures after MCS were more common in pediatrics than in adults. In addition, the incidence of EEG seizure after ECMO was higher than CPB both in adults and children. It is expected that appropriate measures should be taken to control modifiable risk factors, thus improving the prognosis and increasing the long-term survival rate of MCS patients.Systematic Review Registration[https://www.crd.york.ac.uk/prospero], identifier [CRD42021287288].
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14
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Azapagasi E, Kendirli T, Tunçer GO, Perk O, Isikhan SY, Tıras ST, Eyileten Z, Ince E, Uysalel A, Akar AR. Early Neurologic Complications and Long-term Neurologic Outcomes of Extracorporeal Membrane Oxygenation Performed in Children. KLINISCHE PADIATRIE 2022; 234:96-104. [PMID: 35189653 DOI: 10.1055/a-1749-6096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND We aimed at evaluating acute neurologic complications (ANC) and clinical outcome at a 2-year follow-up in children after extracorporeal membrane oxygenation (ECMO). METHODS We conducted a single-center, retrospective review of our patient cohort aged between 1 month and 18 years at the time of ECMO support (between June 2014 to January 2017). Outcome analysis included ANC and their clinical consequences.The Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) were used for neurologic assessment performed at discharge from the hospital and at 2nd year follow-up. RESULTS There were 35 children who required ECMO. The median ECMO time was 9 days (range 2-32 days). Decannulation from ECMO was achieved in 68.6% of patients, and overall, 42.8% survived (15 patients), The incidence of ANC in the surviving patients was 40% (6 children). ANC were intracranial hemorrhage, seizures, cerebral infarction, which occurred in one, two and three of the 15 surviving patients respectively (6.6, 13.3 and 20%). A higher rate of organ failure was related to death (p=0.043), whereas duration on ECMO was a risk factor for the development of ANC (p<0.05). At hospital discharge, the 14 patients evaluated had normal development or -mild disability in 73.2%, and at the 2-year follow-up, 93.4% had these scores. CONCLUSION Children who receive ECMO have a risk to develop ANC, which was related to the length of ECMO treatment, while survival was related to less organ failure, Long-term neurological outcome was good in our patient cohort.
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Affiliation(s)
- Ebru Azapagasi
- Pediatric Intensive Care, Dr Sami Ulus Gynecology Obstetrics and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Tanıl Kendirli
- Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gokcen Oz Tunçer
- Pediatric Neurology , Ankara University Faculty of Medicine, Ankara, Turkey
| | - Oktay Perk
- Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| | | | - Serap Teber Tıras
- Pediatric Neurology , Ankara University Faculty of Medicine, Ankara, Turkey
| | - Zeynep Eyileten
- Pediatric Cardiac Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Erdal Ince
- Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Adnan Uysalel
- Pediatric Cardiac Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ahmet Rüçhan Akar
- Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
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15
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Pollak U, Feinstein Y, Mannarino CN, McBride ME, Mendonca M, Keizman E, Mishaly D, van Leeuwen G, Roeleveld PP, Koers L, Klugman D. The horizon of pediatric cardiac critical care. Front Pediatr 2022; 10:863868. [PMID: 36186624 PMCID: PMC9523119 DOI: 10.3389/fped.2022.863868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/22/2022] [Indexed: 11/21/2022] Open
Abstract
Pediatric Cardiac Critical Care (PCCC) is a challenging discipline where decisions require a high degree of preparation and clinical expertise. In the modern era, outcomes of neonates and children with congenital heart defects have dramatically improved, largely by transformative technologies and an expanding collection of pharmacotherapies. Exponential advances in science and technology are occurring at a breathtaking rate, and applying these advances to the PCCC patient is essential to further advancing the science and practice of the field. In this article, we identified and elaborate on seven key elements within the PCCC that will pave the way for the future.
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Affiliation(s)
- Uri Pollak
- Section of Pediatric Critical Care, Hadassah University Medical Center, Jerusalem, Israel.,Faculty of Medicine, the Hebrew University of Jerusalem, Jerusalem, Israel
| | - Yael Feinstein
- Pediatric Intensive Care Unit, Soroka University Medical Center, Be'er Sheva, Israel.,Faculty of Health Sciences, Ben-Gurion University of the Negev, Be'er Sheva, Israel
| | - Candace N Mannarino
- Divisions of Cardiology and Critical Care Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Mary E McBride
- Divisions of Cardiology and Critical Care Medicine, Departments of Pediatrics and Medical Education, Northwestern University Feinberg School of Medicine, Ann & Robert H Lurie Children's Hospital of Chicago, Chicago, IL, United States
| | - Malaika Mendonca
- Pediatric Intensive Care Unit, Children's Hospital, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Eitan Keizman
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, The Chaim Sheba Medical Center, Tel Hashomer, Israel
| | - David Mishaly
- Pediatric and Congenital Cardiac Surgery, Edmond J. Safra International Congenital Heart Center, The Chaim Sheba Medical Center, The Edmond and Lily Safra Children's Hospital, Tel Hashomer, Israel
| | - Grace van Leeuwen
- Pediatric Cardiac Intensive Care Unit, Sidra Medicine, Ar-Rayyan, Qatar.,Department of Pediatrics, Weill Cornell Medicine, Ar-Rayyan, Qatar
| | - Peter P Roeleveld
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Lena Koers
- Department of Pediatric Intensive Care, Leiden University Medical Center, Leiden, Netherlands
| | - Darren Klugman
- Pediatrics Cardiac Critical Care Unit, Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Johns Hopkins Medicine, Baltimore, MD, United States
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16
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Boeken U, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S. S3 Guideline of Extracorporeal Circulation (ECLS/ECMO) for Cardiocirculatory Failure. Thorac Cardiovasc Surg 2021; 69:S121-S212. [PMID: 34655070 DOI: 10.1055/s-0041-1735490] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, German
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management; Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dirk Buchwald
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
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17
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Malfertheiner MV, Koch A, Fisser C, Millar JE, Maier LS, Zeman F, Poschenrieder F, Lubnow M, Philipp A, Müller T. Incidence of early intra-cranial bleeding and ischaemia in adult veno-arterial extracorporeal membrane oxygenation and extracorporeal cardiopulmonary resuscitation patients: a retrospective analysis of risk factors. Perfusion 2021; 35:8-17. [PMID: 32397881 DOI: 10.1177/0267659120907438] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cerebral complications in veno-arterial extracorporeal membrane oxygenation are known to have a strong impact on mortality and morbidity. Aim of this study is to investigate the early incidence, risk factors and in-hospital mortality of intra-cranial ischaemia and haemorrhage in adults undergoing veno-arterial extracorporeal membrane oxygenation treatment. METHODS This study is a single-centre retrospective analysis on adult patients undergoing veno-arterial extracorporeal membrane oxygenation for different indications. The inclusion criterion included patients with early routine cerebral computed tomography imaging during extracorporeal membrane oxygenation, with no clinical evidence of cerebral pathology prior to cannulation. Cerebral complications were grouped by aetiology and the territories of the brain's supplying arteries. RESULTS One hundred eighty-seven adult patients with a total of 190 veno-arterial extracorporeal membrane oxygenation treatments were included. A total of 16.3% (n = 31) had evidence of either cerebral ischaemia (11.1%) or haemorrhage (5.8%); one patient suffered from both. Cerebral computed tomography scans were performed early in median on the first day after extracorporeal membrane oxygenation cannulation; in-hospital mortality of intra-cranial ischaemia and haemorrhage was 71.4% and 45.5%, respectively. Associated with an increased risk for ischaemic lesions were cannulation of the ascending aorta, higher age, presence of an autoimmune disease and cardiac surgery prior to veno-arterial extracorporeal membrane oxygenation. An association with haemorrhagic lesions was found for a lower blood PaCO2 at 2 hours, lower blood flow through the extracorporeal membrane oxygenation device at 2 hours, higher international normalized ratio and constantly higher activated partial thromboplastin time values as well as higher mean arterial pressures until haemorrhagic lesions were evident. CONCLUSION Cerebral complications are frequent in patients on veno-arterial extracorporeal membrane oxygenation and may be clinically silent events. Careful monitoring with routine neuroimaging seems to be the most appropriate diagnostic approach at present. Intra-cranial ischaemia occurs more frequent than haemorrhage and is associated with cannulation of the aorta ascendens.
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Affiliation(s)
| | - Andrea Koch
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Christoph Fisser
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Jonathan Edward Millar
- Critical Care Research Group, Faculty of Medicine, The University of Queensland, Brisbane, QLD, Australia
| | - Lars Sigfried Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Florian Zeman
- Center for Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | | | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Alois Philipp
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Thomas Müller
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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18
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Identifying Injury to Improve Care in Infant Extracorporeal Membrane Oxygenation: Why Autopsy Is Important. Pediatr Crit Care Med 2021; 22:334-336. [PMID: 33657617 DOI: 10.1097/pcc.0000000000002624] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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19
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Hou JY, Wang CS, Lai H, Sun YX, Li X, Zheng JL, Wang H, Luo JC, Tu GW, Luo Z. Veno-Arterial Extracorporeal Membrane Oxygenation for Patients Undergoing Acute Type A Aortic Dissection Surgery: A Six-Year Experience. Front Cardiovasc Med 2021; 8:652527. [PMID: 34079828 PMCID: PMC8165157 DOI: 10.3389/fcvm.2021.652527] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 04/16/2021] [Indexed: 02/05/2023] Open
Abstract
Objectives: Acute type A aortic dissection (aTAAD) is usually lethal without emergency surgery. Although veno-arterial extracorporeal membrane oxygenation (VA-ECMO) is widely used in patients with cardiogenic shock following cardiac surgery, VA-ECMO support following aTAAD surgery has not been well-described. Based on our 6-year experience, we aimed to retrospectively analyze risk factors, application and timing of VA-ECMO, and outcomes in aTAAD patients. Methods: In this retrospective, single-center study, we enrolled adult patients who underwent aTAAD surgery from January 2014 to December 2019 and were supported with VA-ECMO. Patients were divided into two groups according to whether or not they were successfully weaned from VA-ECMO. Preoperative, intraoperative and postoperative variables were assessed and analyzed. Outcomes of the patients were followed up until discharge. Results: Twenty-seven patients who received aTAAD surgery with VA-ECMO support were included in the study. Nine patients (33.3%) were successfully weaned from VA-ECMO. The median VA-ECMO support time and length of hospital stay in the successfully weaned group were significantly longer than in the group could not be successfully weaned (192 [111-327] vs. 55 [23-95] h, p < 0.01; 29 [18-40] vs. 4 [3-8] days, p < 0.01). Overall in-hospital mortality was 81.5%. The main causes of death were bleeding (37%), neurological complications (15%), and multiple organ dysfunction syndrome (15%). Preoperative levels of creatine kinase-MB (CK-MB) were lower in patients who were successfully weaned from VA-ECMO than in the failed group (14 [6-30] vs. 55 [28-138] U/L, p < 0.01). Postoperative peak levels of CK-MB, cardiac troponin T, lactate dehydrogenase, and lactate were significantly lower in the successful group than in the failed group. Conclusion: Postoperative VA-ECMO support was rarely used in aTAAD patients. Our study showed that VA-ECMO can be considered as a salvage treatment in aTAAD patients, despite the high rate of complications and mortality.
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Affiliation(s)
- Jun-yi Hou
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Chun-sheng Wang
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hao Lai
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Yong-xin Sun
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Xin Li
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Ji-li Zheng
- Department of Nursing, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Huan Wang
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Jing-chao Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-wei Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- *Correspondence: Guo-wei Tu
| | - Zhe Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
- Department of Critical Care Medicine, Xiamen Branch, Zhongshan Hospital, Fudan University, Xiamen, China
- Zhe Luo
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20
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Chen S, Fang F, Liu W, Liu C, Xu F. Cerebral Tissue Regional Oxygen Saturation as a Valuable Monitoring Parameter in Pediatric Patients Undergoing Extracorporeal Membrane Oxygenation. Front Pediatr 2021; 9:669683. [PMID: 34178887 PMCID: PMC8220806 DOI: 10.3389/fped.2021.669683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/04/2021] [Indexed: 12/16/2022] Open
Abstract
Objective: Brain function monitoring technology for extracorporeal membrane oxygenation (ECMO) support has been developing quite slowly. Our objective was to explore the data distribution, variation trend, and variability of cerebral tissue regional oxygen saturation (CrSO2) in pediatric patients undergoing ECMO. Methods: Eight patients who received venoarterial ECMO (V-A ECMO) were included in our study. All of them accepted continuous CrSO2 monitoring by near-infrared spectroscopy (NIRS) within 12 h of ECMO initiation until ECMO wean. Differences in the CrSO2 distribution characteristic, the variation trend of daily CrSO2, and the variability of CrSO2 for the first 5 days following ECMO initiation were compared between survivors and non-survivors according to pediatric intensive care unit (PICU) mortality. Results: The percentage of time of CrSO2 <60% against the whole monitoring time was significantly lower in survivors in both hemispheres {right: 4.34% [interquartile range (IQR) = 0.39-8.55%] vs. 47.45% [IQR = 36.03-64.52%], p = 0.036; left: 0.40% [IQR = 0.01-1.15%] vs. 30.9% [IQR = 26.92-49.62%], p = 0.036}. Survivors had significantly higher CrSO2 on the first 4 days. Root mean of successive squared differences (RMSSD), the variability variable of CrSO2, was significantly lower in survivors (right: 3.29 ± 0.79 vs. 6.16 ± 0.67, p = 0.002; left: 3.56 ± 1.20 vs. 6.04 ± 1.44, p = 0.039). Conclusion: Lower CrSO2, CrSO2 <60% over a longer period of time, and higher fluctuation of CrSO2 are likely associated with PICU mortality in pediatric patients undergoing V-A ECMO. Clinical Trial Registry: URL: http://www.chictr.org.cn/showproj.aspx?proj=46639, trial registry number: ChiCTR1900028021.
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Affiliation(s)
- Song Chen
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Fang Fang
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Wenjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chengjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Feng Xu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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21
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Busch DR, Baker WB, Mavroudis CD, Ko TS, Lynch JM, McCarthy AL, DuPont-Thibodeau G, Buckley EM, Jacobwitz M, Boorady TW, Mensah-Brown K, Connelly JT, Yodh AG, Kilbaugh TJ, Licht DJ. Noninvasive optical measurement of microvascular cerebral hemodynamics and autoregulation in the neonatal ECMO patient. Pediatr Res 2020; 88:925-933. [PMID: 32172282 PMCID: PMC7492409 DOI: 10.1038/s41390-020-0841-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 02/12/2020] [Accepted: 02/19/2020] [Indexed: 01/14/2023]
Abstract
BACKGROUND Extra-corporeal membrane oxygenation (ECMO) is a life-saving intervention for severe respiratory and cardiac diseases. However, 50% of survivors have abnormal neurologic exams. Current ECMO management is guided by systemic metrics, which may poorly predict cerebral perfusion. Continuous optical monitoring of cerebral hemodynamics during ECMO holds potential to detect risk factors of brain injury such as impaired cerebrovascular autoregulation (CA). METHODS We conducted daily measurements of microvascular cerebral blood flow (CBF), oxygen saturation, and total hemoglobin concentration using diffuse correlation spectroscopy (DCS) and frequency-domain diffuse optical spectroscopy in nine neonates. We characterize CA utilizing the correlation coefficient (DCSx) between CBF and mean arterial blood pressure (MAP) during ECMO pump flow changes. RESULTS Average MAP and pump flow levels were weakly correlated with CBF and were not correlated with cerebral oxygen saturation. CA integrity varied between individuals and with time. Systemic measurements of MAP, pulse pressure, and left cardiac dysfunction were not predictive of impaired CA. CONCLUSIONS Our pilot results suggest that systemic measures alone cannot distinguish impaired CA from intact CA during ECMO. Furthermore, optical neuromonitoring could help determine patient-specific ECMO pump flows for optimal CA integrity, thereby reducing risk of secondary brain injury. IMPACT Cerebral blood flow and oxygenation are not well predicted by systemic proxies such as ECMO pump flow or blood pressure. Continuous, quantitative, bedside monitoring of cerebral blood flow and oxygenation with optical tools enables new insight into the adequacy of cerebral perfusion during ECMO. A demonstration of hybrid diffuse optical and correlation spectroscopies to continuously measure cerebral blood oxygen saturation and flow in patients on ECMO, enabling assessment of cerebral autoregulation. An observation of poor correlation of cerebral blood flow and oxygenation with systemic mean arterial pressure and ECMO pump flow, suggesting that clinical decision making guided by target values for these surrogates may not be neuroprotective. ~50% of ECMO survivors have long-term neurological deficiencies; continuous monitoring of brain health throughout therapy may reduce these tragically common sequelae through brain-focused adjustment of ECMO parameters.
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Affiliation(s)
- David R Busch
- Departments of Anesthesiology & Pain Management and Neurology & Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Wesley B Baker
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Constantine D Mavroudis
- Division of Cardiovascular Surgery, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Tiffany S Ko
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | - Jennifer M Lynch
- Department of Anesthesiology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Ann L McCarthy
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | | | - Erin M Buckley
- Wallace H. Coulter Department of Biomedical Engineering, Georgia Institute of Technology and Emory University, Atlanta, GA, USA
- Department of Pediatrics, School of Medicine, Emory University, Atlanta, GA, USA
| | - Marin Jacobwitz
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Timothy W Boorady
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kobina Mensah-Brown
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - James T Connelly
- ECMO Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Arjun G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA, USA
| | - Todd J Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Daniel J Licht
- Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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22
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Peluso L, Rechichi S, Franchi F, Pozzebon S, Scolletta S, Brasseur A, Legros B, Vincent JL, Creteur J, Gaspard N, Taccone FS. Electroencephalographic features in patients undergoing extracorporeal membrane oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:629. [PMID: 33126887 PMCID: PMC7598240 DOI: 10.1186/s13054-020-03353-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/21/2020] [Indexed: 11/10/2022]
Abstract
Background Neurologic injury is one of the most frequent causes of death in patients undergoing extracorporeal membrane oxygenation (ECMO). As neurological examination is often unreliable in sedated patients, additional neuromonitoring is needed. However, the value of electroencephalogram (EEG) in adult ECMO patients has not been well assessed. Therefore, the aim of this study was to assess the occurrence of electroencephalographic abnormalities in patients treated with extracorporeal membrane oxygenation (ECMO) and their association with 3-month neurologic outcome.
Methods Retrospective analysis of all patients undergoing venous–venous (V–V) or venous–arterial (V–A) ECMO with a concomitant EEG recording (April 2009–December 2018), either recorded intermittently or continuously. EEG background was classified into four categories: mild/moderate encephalopathy (i.e., mostly defined by the presence of reactivity), severe encephalopathy (mostly defined by the absence of reactivity), burst-suppression (BS) and suppressed background. Epileptiform activity (i.e., ictal EEG pattern, sporadic epileptiform discharges or periodic discharges) and asymmetry were also reported. EEG findings were analyzed according to unfavorable neurological outcome (UO, defined as Glasgow Outcome Scale < 4) at 3 months after discharge. Results A total of 139 patients (54 [41–62] years; 60 (43%) male gender) out of 596 met the inclusion criteria and were analyzed. Veno–arterial (V–A) ECMO was used in 98 (71%); UO occurred in 99 (71%) patients. Continuous EEG was performed in 113 (81%) patients. The analysis of EEG background showed that 29 (21%) patients had severe encephalopathy, 4 (3%) had BS and 19 (14%) a suppressed background. In addition, 11 (8%) of patients had seizures or status epilepticus, 10 (7%) had generalized periodic discharges or lateralized periodic discharges, and 27 (19%) had asymmetry on EEG. In the multivariate analysis, the occurrence of ischemic stroke or intracranial hemorrhage (OR 4.57 [1.25–16.74]; p = 0.02) and a suppressed background (OR 10.08 [1.24–82.20]; p = 0.03) were independently associated with UO. After an adjustment for covariates, an increasing probability for UO was observed with more severe EEG background categories. Conclusions In adult patients treated with ECMO, EEG can identify patients with a high likelihood of poor outcome. In particular, suppressed background was independently associated with unfavorable neurological outcome.
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Affiliation(s)
- Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Serena Rechichi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.,Department of Medical Biotechnologies, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy
| | - Federico Franchi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.,Department of Medical Biotechnologies, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy
| | - Selene Pozzebon
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.,Department of Medical Biotechnologies, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy
| | - Sabino Scolletta
- Department of Medical Biotechnologies, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy
| | - Alexandre Brasseur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Benjamin Legros
- Department of Neurology Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.,Department of Neurology, Yale University Medical School, 15, York Street, New Haven, CT, 06510, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
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23
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Fox J, Jenks CL, Farhat A, Li X, Liu Y, James E, Karasick S, Morriss MC, Sirsi D, Raman L. EEG is A Predictor of Neuroimaging Abnormalities in Pediatric Extracorporeal Membrane Oxygenation. J Clin Med 2020; 9:jcm9082512. [PMID: 32759731 PMCID: PMC7463499 DOI: 10.3390/jcm9082512] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 07/23/2020] [Accepted: 07/24/2020] [Indexed: 12/31/2022] Open
Abstract
The goal of this project was to evaluate if severity of electroencephalogram (EEG) during or shortly after being placed on extracorporeal membrane oxygenation (ECMO) would correlate with neuroimaging abnormalities, and if that could be used as an early indicator of neurologic injury. This was a retrospective chart review spanning November 2009 to May 2018. Patients who had an EEG recording during ECMO or within 48 hours after being decannulated (early group) or within 3 months of being on ECMO (late group) were included if they also had ECMO-related neuroimaging. In the early EEG group, severity of the EEG findings of mild, moderate, and severe EEG correlated to mild, moderate, and severe neuroimaging scores. Patients on venoarterial (VA) ECMO were noted to have higher EEG and neuroimaging severity; this was statistically significant. There was no association in the late EEG group to neuroimaging abnormalities. Our study highlights that EEG severity can be an early predictor for neuroimaging abnormalities that can be identified by computed tomography (CT) and or magnetic resonance imaging (MRI). This can provide guidance for both the medical team and families, allowing for a better understanding of overall prognosis.
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Affiliation(s)
- Jordana Fox
- Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, AZ 85016, USA;
| | | | - Abdelaziz Farhat
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390, USA; (A.F.); (D.S.)
- Children’s Medical Center of Dallas, Dallas, TX 75235, USA; (E.J.); (S.K.); (M.C.M.)
| | - Xilong Li
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (X.L.); (Y.L.)
| | - Yulun Liu
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA; (X.L.); (Y.L.)
| | - Ellen James
- Children’s Medical Center of Dallas, Dallas, TX 75235, USA; (E.J.); (S.K.); (M.C.M.)
| | - Stephanie Karasick
- Children’s Medical Center of Dallas, Dallas, TX 75235, USA; (E.J.); (S.K.); (M.C.M.)
| | - Michael C. Morriss
- Children’s Medical Center of Dallas, Dallas, TX 75235, USA; (E.J.); (S.K.); (M.C.M.)
- Department of Radiology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Deepa Sirsi
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390, USA; (A.F.); (D.S.)
- Children’s Medical Center of Dallas, Dallas, TX 75235, USA; (E.J.); (S.K.); (M.C.M.)
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center at Dallas, Dallas, TX 75390, USA; (A.F.); (D.S.)
- Children’s Medical Center of Dallas, Dallas, TX 75235, USA; (E.J.); (S.K.); (M.C.M.)
- Correspondence:
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24
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Electrographic Seizures and Brain Injury in Children Requiring Extracorporeal Membrane Oxygenation. Pediatr Neurol 2020; 108:77-85. [PMID: 32299743 DOI: 10.1016/j.pediatrneurol.2020.03.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/23/2020] [Accepted: 03/01/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Single-center studies suggest that up to 30% of children undergoing extracorporeal membrane oxygenation have electrographic seizures. The aim of this study was to characterize seizure prevalence, seizure risk factors, and brain injury prevalence in the pediatric extracorporeal membrane oxygenation population at a tertiary care children's hospital. METHODS We performed a retrospective systematic review of medical records for 86 consecutive children (neonates to age 21 years) who received Neurology consults and continuous video electroencephalography while undergoing extracorporeal membrane oxygenation from November 2015 to September 2018. RESULTS Continuous video electroencephalography was initiated in 86 of 170 children who required extracorporeal membrane oxygenation (51%); median duration of continuous vodeo electroencephalography was four days. Nineteen of 86 had electroencephalography-confirmed seizures (22%). Sixteen of 19 had seizures within the first 48 hours on continuous video electroencephalography. Interictal epileptiform discharges were a significant risk factor for seizures; 89% of those with seizures versus 46% of those without had interictal epileptiform discharges (P < 0.001, Fisher's exact test). Children with seizures also had higher pericannulation lactate (median 6.7, interquartile range of 4.3 to 19.0 for those with, and median 4.0, interquartile range of 2.0 to 7.3 for those without; P = 0.02, Mann-Whitney U test). Seizures were associated with hemorrhage on neuroimaging (68% of children with seizures had intracranial hemorrhage versus 34% of those without, P = 0.01, chi-square test). CONCLUSION Approximately half the children undergoing extracorporeal membrane oxygenation received continuous video electroencephalography during the study period, and 22% had seizures. Interictal epileptiform discharges and elevated pre-extracorporeal membrane oxygenation lactate levels were risk factors for seizures; seizures were associated with intracranial hemorrhage.
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25
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Felli A, Skhirtladze-Dworschak K, Opfermann P, Dworschak M. Limitations of Cerebral Oximetry in a Patient With an Intracerebral Hemorrhage and Brain Edema on Extracorporeal Membrane Oxygenation: A Case Report. A A Pract 2019; 12:390-392. [PMID: 31162164 DOI: 10.1213/xaa.0000000000000940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Regional cerebral tissue saturation monitoring is frequently used in patients on mechanical cardiac assist devices with the intention to promptly detect critical imbalances between cerebral oxygen delivery and oxygen extraction and ultimately circumvent permanent brain injury. We report a case where an intraparenchymal bleed in the supply zone of the middle cerebral artery-followed by severe hemispherical brain edema, leading to life-threatening intracranial hypertension-escaped cerebral oximetry monitoring using near-infrared spectroscopy. Potential explanations for our observation, as well as the specific limitations of these devices, are discussed.
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Affiliation(s)
- Alessia Felli
- From the Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, General Hospital Vienna, Medical University of Vienna, Vienna, Austria
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Can Cerebral Near-infrared Spectroscopy Predict Cerebral Ischemic Events in Neurosurgical Patients? A Narrative Review of the Literature. J Neurosurg Anesthesiol 2019; 31:378-384. [DOI: 10.1097/ana.0000000000000522] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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27
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Silberman AP, Cheung EW. Neurodevelopmental Outcomes After Neonatal and Pediatric ECMO. CURRENT PEDIATRICS REPORTS 2019. [DOI: 10.1007/s40124-019-00194-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Prevalence of Seizures in Pediatric Extracorporeal Membrane Oxygenation Patients as Measured by Continuous Electroencephalography. Pediatr Crit Care Med 2018; 19:1162-1167. [PMID: 30247227 DOI: 10.1097/pcc.0000000000001730] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Standards for neuromonitoring during extracorporeal membrane oxygenation support do not currently exist, and there is wide variability in practice. We present our institutional experience at an academic children's hospital since establishment of a continuous electroencephalography monitoring protocol for extracorporeal membrane oxygenation patients. DESIGN Retrospective, single-center study. SETTING Neonatal ICU and PICU in an urban, quaternary care center. PATIENTS All neonatal and pediatric patients requiring extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS During the study period, 70 patients were cannulated for extracorporeal membrane oxygenation and had continuous electroencephalography monitoring for greater than 24 hours. Electroencephalographic seizures were observed in 16 of 70 patients (23%), including five patients (7%) who were in status epilepticus. Among patients with continuous electroencephalography seizures, nine (56%) had subclinical nonconvulsive status epilepticus and eight (50%) had seizures in the initial 24 hours of extracorporeal membrane oxygenation support. Survival to hospital discharge was significantly greater for extracorporeal membrane oxygenation patients without seizures (74% vs 44%; p = 0.02). CONCLUSIONS Seizures occur in a significant proportion of pediatric and neonatal extracorporeal membrane oxygenation patients, frequently in the initial 24 hours after extracorporeal membrane oxygenation cannulation. Because seizures are associated with significantly decreased survival, neuromonitoring early in the extracorporeal membrane oxygenation course is important and useful. Further studies are needed to correlate electroencephalography findings with neurologic outcome.
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Brain Magnetic Resonance Imaging Findings in Pediatric Patients Post Extracorporeal Membrane Oxygenation. ASAIO J 2018; 63:810-814. [PMID: 29084038 DOI: 10.1097/mat.0000000000000580] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Neurologic complications can occur with extracorporeal membrane oxygenation (ECMO) due to several factors. Prior studies identified neonates as having unique risk factors and neuroimaging findings post ECMO. The aim of this study is to describe brain magnetic resonance imaging findings of pediatric patients treated with ECMO. We conducted a retrospective study of nonneonatal pediatric patients who underwent a comprehensive brain magnetic resonance imaging after ECMO between January 2000 and July 2015. We identified 47 pediatric patients in the study cohort with a median age of 8 months (interquartile range 3-170 months) and a median ECMO run duration of 7.15 days (interquartile range 3.8-10.3 days). Among indications for ECMO cannulation, 12 (25.5%) were cardiac, 23 (48.9%) were respiratory, and 12 (25.5%) were extracorporeal cardiopulmonary resuscitation cannulations. There were 33 (70.2%) veno-arterial cannulations of which 14 (42%) were transthoracic cannulations. There were 13 patients (27.7%) with an overall incidence of stroke: 8 patients had exclusive ischemic strokes, 2 had hemorrhagic strokes, and 3 had mixed types of stroke. The number of strokes in patients on veno-arterial ECMO was significantly decreased in patients undergoing transthoracic cannulation when compared with peripheral cannulation (7 vs. 42%, p = 0.05). Further study will be used to identify risk factors for neurological injury after ECMO and to look for outcome predictors based on neuroradiologic findings.
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Cerebral Pathophysiology in Extracorporeal Membrane Oxygenation: Pitfalls in Daily Clinical Management. Crit Care Res Pract 2018; 2018:3237810. [PMID: 29744226 PMCID: PMC5878897 DOI: 10.1155/2018/3237810] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2017] [Revised: 01/24/2018] [Accepted: 02/12/2018] [Indexed: 12/12/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a life-saving technique that is widely being used in centers throughout the world. However, there is a paucity of literature surrounding the mechanisms affecting cerebral physiology while on ECMO. Studies have shown alterations in cerebral blood flow characteristics and subsequently autoregulation. Furthermore, the mechanical aspects of the ECMO circuit itself may affect cerebral circulation. The nature of these physiological/pathophysiological changes can lead to profound neurological complications. This review aims at describing the changes to normal cerebral autoregulation during ECMO, illustrating the various neuromonitoring tools available to assess markers of cerebral autoregulation, and finally discussing potential neurological complications that are associated with ECMO.
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Abstract
Utilization of extraocorporeal membrane oxygenation (ECMO) has become increasingly widespread as a bridging therapy for neonates with severe, reversible respiratory or cardiac diseases. While significant risks remain, due to advances in medical and surgical management, overall mortality has decreased. However, short and long-term neurological morbidity has remained high. Therefore, increasing attention has been focused on multimodal neuromonitoring to track and optimally, minimize or prevent intracranial injury. This review will explore the the indications, advantages, disadvantages, timing, frequency, duration, and any known correlation with neurodevelopmental outcomes of common types of neuromonitoring in the neonatal ECMO population. Investigational monitoring techniques such as NIRS will be briefly reviewed.
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Affiliation(s)
- Nan Lin
- Division of Neurology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - John Flibotte
- Division of Neonatology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104
| | - Daniel J Licht
- Division of Neurology, The Children's Hospital of Philadelphia, 3401 Civic Center Blvd, Philadelphia, PA 19104.
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Xie A, Lo P, Yan TD, Forrest P. Neurologic Complications of Extracorporeal Membrane Oxygenation: A Review. J Cardiothorac Vasc Anesth 2017. [DOI: 10.1053/j.jvca.2017.03.001] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Lorusso R. Extracorporeal life support and neurologic complications: still a long way to go. J Thorac Dis 2017; 9:E954-E956. [PMID: 29266103 DOI: 10.21037/jtd.2017.09.30] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
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Pappalardo F, Montisci A. Neurologic complications during V-V extracorporeal membrane oxygenation: still counting…. J Thorac Dis 2017; 9:2774-2776. [PMID: 29221237 DOI: 10.21037/jtd.2017.08.62] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Affiliation(s)
- Federico Pappalardo
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Andrea Montisci
- Cardiothoracic Center, Istituto Clinico Sant'Ambrogio, Gruppo Ospedaliero San Donato, Milan, Italy
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Hosseinpour AR, van Steenberghe M, Bernath MA, Di Bernardo S, Pérez MH, Longchamp D, Dolci M, Boegli Y, Sekarski N, Orrit J, Hurni M, Prêtre R, Cotting J. Improvement in perioperative care in pediatric cardiac surgery by shifting the primary focus of treatment from cardiac output to perfusion pressure: Are beta stimulants still needed? CONGENIT HEART DIS 2017; 12:570-577. [DOI: 10.1111/chd.12485] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Accepted: 05/11/2017] [Indexed: 11/30/2022]
Affiliation(s)
| | | | - Marc-André Bernath
- Department of Pediatric Anesthesiology; University Hospital of Vaud; Lausanne Switzerland
| | - Stefano Di Bernardo
- Department of Pediatric Cardiology; University Hospital of Vaud; Lausanne Switzerland
| | - Marie-Hélène Pérez
- Department of Pediatric Intensive Care; University Hospital of Vaud; Lausanne Switzerland
| | - David Longchamp
- Department of Pediatric Intensive Care; University Hospital of Vaud; Lausanne Switzerland
| | - Mirko Dolci
- Department of Pediatric Anesthesiology; University Hospital of Vaud; Lausanne Switzerland
| | - Yann Boegli
- Department of Pediatric Anesthesiology; University Hospital of Vaud; Lausanne Switzerland
| | - Nicole Sekarski
- Department of Pediatric Cardiology; University Hospital of Vaud; Lausanne Switzerland
| | - Javier Orrit
- Department of Cardiac Surgery; University Hospital of Vaud; Lausanne Switzerland
| | - Michel Hurni
- Department of Cardiac Surgery; University Hospital of Vaud; Lausanne Switzerland
| | - René Prêtre
- Department of Cardiac Surgery; University Hospital of Vaud; Lausanne Switzerland
| | - Jacques Cotting
- Department of Pediatric Intensive Care; University Hospital of Vaud; Lausanne Switzerland
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Is Functional Status Scale a Reliable Measure of Neurologic Outcome Post Extracorporeal Membrane Oxygenation? Pediatr Crit Care Med 2017; 18:599-601. [PMID: 28574910 DOI: 10.1097/pcc.0000000000001162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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37
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Loftsgard TO, Newcome MD, Hanneman MR, Patch RK, Seelhammer TG. Management of Neurogenic Pulmonary Edema and Differential Hypoxemia in an Adult Supported on Venoarterial Extracorporeal Membrane Oxygenation. J Cardiothorac Vasc Anesth 2017; 31:2170-2174. [PMID: 28764986 DOI: 10.1053/j.jvca.2017.03.044] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2016] [Indexed: 11/11/2022]
Affiliation(s)
- Theodore O Loftsgard
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN; Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN
| | - Marci D Newcome
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN; Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN
| | - Maria R Hanneman
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN
| | - Richard K Patch
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN
| | - Troy G Seelhammer
- Critical Care Independent Multidisciplinary Program, Mayo Clinic, Rochester, MN; Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN.
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Abstract
OBJECTIVE We aimed to determine the prevalence and risk factors for electrographic seizures in neonates and children requiring extracorporeal membrane oxygenation support. DESIGN Prospective quality improvement project. SETTING Quaternary care pediatric institution. PATIENTS Consistent with American Clinical Neurophysiology Society electroencephalographic monitoring recommendations, neonates and children requiring extracorporeal membrane oxygenation support underwent clinically indicated electroencephalographic monitoring. INTERVENTIONS We performed a 2-year quality improvement study from July 2013 to June 2015 evaluating electrographic seizure prevalence and risk factors. MAIN RESULTS Ninety-nine of 112 patients (88%) requiring extracorporeal membrane oxygenation support underwent electroencephalographic monitoring. Electrographic seizures occurred in 18 patients (18%), of whom 11 patients (61%) had electrographic status epilepticus and 15 patients (83%) had exclusively electrographic-only seizures. Electrographic seizures were more common in patients with low cardiac output syndrome (p = 0.03). Patients with electrographic seizures were more likely to die prior to discharge (72% vs 30%; p = 0.01) and have unfavorable outcomes (54% vs 17%; p = 0.004) than those without electrographic seizures. CONCLUSIONS Electrographic seizures occurred in 18% of neonates and children requiring extracorporeal membrane oxygenation support, often constituted electrographic status epilepticus, and were often electrographic-only thereby requiring electroencephalographic monitoring for identification. Low cardiac output syndrome was associated with an increased risk for electrographic seizures. Electrographic seizures were associated with higher mortality and unfavorable outcomes. Further investigation is needed to determine whether electrographic seizures identification and management improves outcomes.
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Searching for the Brain's Canary in the Coal Mine. Crit Care Med 2015; 43:2265-6. [PMID: 26376258 DOI: 10.1097/ccm.0000000000001267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Epidemiology of Stroke in Pediatric Cardiac Surgical Patients Supported With Extracorporeal Membrane Oxygenation. Ann Thorac Surg 2015; 100:1751-7. [PMID: 26298170 DOI: 10.1016/j.athoracsur.2015.06.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Revised: 05/01/2015] [Accepted: 06/08/2015] [Indexed: 11/21/2022]
Abstract
BACKGROUND Stroke is a common complication of extracorporeal membrane oxygenation (ECMO), and pediatric cardiac surgical patients may be at higher risk. Epidemiology and risk factors for stroke in these patients are not well characterized. METHODS We analyzed pediatric (<18 years) cardiac ECMO cases in the Extracorporeal Life Support Organization Registry from 2002 to 2013. Cardiac surgical patients were identified, and procedures were stratified according to The Society of Thoracic Surgeons morbidity categories. The primary outcome was any stroke (hemorrhagic or infarction) identified by neuroimaging. Risk factors were identified through multivariable logistic regression. RESULTS We analyzed 3,517 cardiac surgical patients; 81% with cyanotic disease, and 57% in high-risk categories from The Society of Thoracic Surgeons (categories 4 and 5). Overall, 12% experienced stroke while receiving ECMO, and those with stroke had greater in-hospital mortality (72% versus 51%; p < 0.0001). In multivariable analysis, neonatal status (adjusted odds ratio, 1.8; 95% confidence interval, 1.3 to 2.4), lower weight-for-age z score (adjusted odds ratio, 1.1 for each 1-point decrease; 95% confidence interval, 1.04 to 1.25), and longer ECMO duration (upper quartile [≥ 167 hours] adjusted odds ratio, 1.4; 95% confidence interval, 1.1 to 1.8) were independently associated with increased stroke risk, whereas cyanotic disease, The Society of Thoracic Surgeons category, and bypass time were not. CONCLUSIONS This multicenter analysis demonstrates that pediatric cardiac surgical patients on ECMO are at high risk of stroke; younger or underweight patients and those with longer ECMO duration are at greatest risk, independent of procedural complexity. Future study is necessary to determine how anticoagulation or other clinical practices can be modified to reduce stroke incidence.
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