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An HY, Kang HJ, Park JD. Outcomes of extracorporeal membrane oxygenation support in pediatric hemato-oncology patients. Acute Crit Care 2024; 39:108-116. [PMID: 38303580 PMCID: PMC11002627 DOI: 10.4266/acc.2023.01088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 12/13/2023] [Accepted: 12/13/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND In this study, we reviewed the outcomes of pediatric patients with malignancies who underwent hematopoietic stem cell transplantation (HSCT) and extracorporeal membrane oxygenation (ECMO). METHODS We retrospectively analyzed the records of pediatric hemato-oncology patients treated with chemotherapy or HSCT and who received ECMO in the pediatric intensive care unit (PICU) at Seoul National University Children's Hospital from January 2012 to December 2020. RESULTS Over a 9-year period, 21 patients (14 males and 7 females) received ECMO at a single pediatric institute; 10 patients (48%) received veno-arterial (VA) ECMO for septic shock (n=5), acute respiratory distress syndrome (ARDS) (n=3), stress-induced myopathy (n=1), or hepatopulmonary syndrome (n=1); and 11 patients (52%) received veno-venous (VV) ECMO for ARDS due to pneumocystis pneumonia (n=1), air leak (n=3), influenza (n=1), pulmonary hemorrhage (n=1), or unknown etiology (n=5). All patients received chemotherapy; 9 received anthracycline drugs and 14 (67%) underwent HSCT. Thirteen patients (62%) were diagnosed with malignancies and 8 (38%) were diagnosed with non-malignant disease. Among the 21 patients, 6 (29%) survived ECMO in the PICU and 5 (24%) survived to hospital discharge. Among patients treated for septic shock, 3 of 5 patients (60%) who underwent ECMO and 5 of 10 patients (50%) who underwent VA ECMO survived. However, all the patients who underwent VA ECMO or VV ECMO for ARDS died. CONCLUSIONS ECMO is a feasible treatment option for respiratory or heart failure in pediatric patients receiving chemotherapy or undergoing HSCT.
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Affiliation(s)
- Hong Yul An
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - Hyoung Jin Kang
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
- Cancer Research Institute, Seoul National University College of Medicine, Seoul, Korea
| | - June Dong Park
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
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2
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The Evolution of Extracorporeal Membrane Oxygenation Circuitry and Impact on Clinical Outcomes in Children: A Systematic Review. ASAIO J 2023; 69:247-253. [PMID: 35749749 DOI: 10.1097/mat.0000000000001785] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
This systematic review summarizes the major developments in extracorporeal membrane oxygenation (ECMO) circuitry in pediatrics over the past 20 years and demonstrates the impacts of those developments on clinical outcomes. This systematic review followed structured Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A total of 1987 studies were retrieved, of which 82 were included in the final analysis. Over the past 20 years, ECMO pumps have shifted from roller pumps to centrifugal pumps. Silicone and polypropylene hollow fiber membrane oxygenators were initially used but have been replaced by polymethylpentene hollow fiber membrane oxygenators, with other ECMO components poorly reported. Considerable variability in mortality was found across studies and there was no statistical difference in mortality rates across different periods. The duration of ECMO and other outcome measures were inconsistently reported across studies. This systematic review demonstrated technological developments in pumps and oxygenators over the last two decades, although patient mortality rates remained unchanged. This could be because of ECMO support applied to patients in more critical conditions over the years. We also highlighted the limitations of methodology information disclosure and outcome measures in current ECMO studies, showing the need of reporting standardization for future ECMO studies.
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Henry BM, Benscoter AL, de Oliveira MHS, Vikse J, Perry T, Cooper DS. Outcomes of extracorporeal life support for respiratory failure in children with primary immunodeficiencies. Perfusion 2023; 38:37-43. [PMID: 34278883 DOI: 10.1177/02676591211033946] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Extracorporeal Membrane Oxygenation (ECMO) may serve as a life-saving rescue therapy in critically ill children with respiratory failure. While survival rates of ECMO in children with secondary immunodeficiency is considered relatively poor, survival rates in children with primary immunodeficiencies (PID) has yet to be thoroughly investigated. DESIGN Retrospective analysis of prospectively collected data from children (29 days-18 years old). PID patients were identified by using International Classification of Diseases (ICD) codes. SETTING Data were retrieved from Extracorporeal Life Support Organization Registry (1989-2018). INTERVENTIONS ECMO for a pulmonary support indication. The survival-to-discharge rate was calculated and factors influencing outcomes were compared between survivors and non-survivors. MEASUREMENTS AND MAIN RESULTS A total of 73 eligible ECMO runs were included. The survival-to-discharge rate in pediatric PID patients was 45.2%. No differences were noted in survival based on type of immunodeficiency (p = 0.42) or decade of support (p = 0.98). There was no difference in the rate of pre-ECMO infection in survivors versus non-survivors (p = 0.69). The survival-to-discharge rate in patients with a culture positive infection during the ECMO run was 45.0% versus 45.3% in those with no infection (p = 0.98). In multivariate analysis, only cardiac complications (OR 5.09, 95% CI: 1.15-22.53), pulmonary complications (OR: 13.00, 95% CI: 1.20-141.25), and neurologic complications (OR: 9.86, 95% CI: 1.64-59.21) were independently associated with increased mortality. CONCLUSION Children with a PID who require extracorporeal life support due to respiratory failure have a reasonable chance of survival and should be considered candidates for ECMO. The presence of a pre-ECMO infection should not be considered an ECMO contraindication.
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Affiliation(s)
- Brandon Michael Henry
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Alexis L Benscoter
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | | | - Jens Vikse
- Clinical Immunology Unit, Stavanger University Hospital, Stavanger, Norway
| | - Tanya Perry
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David S Cooper
- The Heart Institute, Cincinnati Children's Hospital Medical Center, Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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ROBERT B, GUELLEC I, JEGARD J, JEAN S, GUILBERT J, SOREZE Y, STARCK J, PILOQUET JE, LEGER PL, RAMBAUD J. Extracorporeal membrane oxygenation for immunocompromised children with acute respiratory distress syndrome: a French referral center cohort. Minerva Pediatr (Torino) 2022; 74:537-544. [DOI: 10.23736/s2724-5276.20.05725-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Zinter MS, McArthur J, Duncan C, Adams R, Kreml E, Dalton H, Abdel-Azim H, Rowan CM, Gertz SJ, Mahadeo KM, Randolph AG, Rajapreyar P, Steiner ME, Lehmann L. Candidacy for Extracorporeal Life Support in Children After Hematopoietic Cell Transplantation: A Position Paper From the Pediatric Acute Lung Injury and Sepsis Investigators Network's Hematopoietic Cell Transplant and Cancer Immunotherapy Subgroup. Pediatr Crit Care Med 2022; 23:205-213. [PMID: 34878420 PMCID: PMC8897218 DOI: 10.1097/pcc.0000000000002865] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The last decade has seen improved outcomes for children requiring extracorporeal life support as well as for children undergoing hematopoietic cell transplantation. Thus, given the historically poor survival of hematopoietic cell transplantation patients using extracorporeal life support, the Pediatric Acute Lung Injury and Sepsis Investigators' hematopoietic cell transplantation and cancer immunotherapy subgroup aimed to characterize the utility of extracorporeal life support in facilitating recovery from critical cardiorespiratory illnesses in pediatric hematopoietic cell transplantation patients. DATA SOURCES All available published data were identified using a set of PubMed search terms for pediatric extracorporeal life support and hematopoietic cell transplantation. STUDY SELECTION All articles that provided original reports of pediatric hematopoietic cell transplantation patients who underwent extracorporeal life support were included. Sixty-four manuscripts met search criteria. Twenty-four were included as primary reports of pediatric hematopoietic cell transplantation patients who underwent extracorporeal life support (11 were single case reports, four single institution case series, two multi-institution case series, and seven registry reports from Extracorporeal Life Support Organization, Pediatric Heath Information System, and Virtual Pediatric Systems). DATA EXTRACTION All 24 articles were reviewed by first and last authors and a spread sheet was constructed including sample size, potential biases, and conclusions. DATA SYNTHESIS Discussions regarding incorporation of available evidence into our clinical practice were held at biannual meetings, as well as through email and virtual meetings. An expert consensus was determined through these discussions and confirmed through a modified Delphi process. CONCLUSIONS Extracorporeal life support in hematopoietic cell transplantation patients is being used with increasing frequency and potentially improving survival. The Pediatric Acute Lung Injury and Sepsis Investigators hematopoietic cell transplantation-cancer immunotherapy subgroup has developed a framework to guide physicians in decision-making surrounding extracorporeal life support candidacy in pediatric hematopoietic cell transplantation patients. In addition to standard extracorporeal life support considerations, candidacy in the hematopoietic cell transplantation population should consider the following six factors in order of consensus agreement: 1) patient comorbidities; 2) underlying disease necessitating hematopoietic cell transplantation; 3) hematopoietic cell transplantation toxicities, 4) family and patient desires for goals of care; 5) hematopoietic cell transplantation preparatory regimen; and 6) graft characteristics. Although risk assessment may be individualized, data are currently insufficient to clearly delineate ideal candidacy. Therefore, we urge the onco-critical care community to collaborate and capture data to provide better evidence to guide physicians' decision-making in the future.
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Affiliation(s)
- Matt S. Zinter
- Department of Pediatrics, Division of Critical Care Medicine, University of California San Francisco, San Francisco, CA
| | - Jennifer McArthur
- Department of Pediatrics, Division of Critical Care Medicine, St. Jude Children’s Research Hospital, Memphis, TN
- Department of Pediatrics, Division of Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Christine Duncan
- Department of Pediatrics, Division of Hematology/Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
| | - Roberta Adams
- Department of Internal Medicine, Division of Hematology/Oncology. Mayo Clinic, Phoenix, AZ
| | - Erin Kreml
- Department of Child Health, Division of Critical Care Medicine, University of AZ, Phoenix, AZ
| | - Heidi Dalton
- Pediatric Critical Care Medicine, Inova Children’s Hospital, Fairfax, VA
| | - Hisham Abdel-Azim
- Department of Pediatrics, Division of Hematology/Oncology and Transplant and Cell Therapy, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Courtney M. Rowan
- Department of Pediatrics, Division of Critical Care Medicine, Indiana University School of Medicine, Indianapolis, IN
| | - Shira J. Gertz
- Department of Pediatrics, Division of Critical Care Medicine, Saint Barnabas Medical Center, Livingston, NJ
| | - Kris M. Mahadeo
- Department of Pediatrics, Division of Hematology/Oncology, MD Anderson Cancer Center, Houston, TX
| | - Adrienne G. Randolph
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, MA
| | - Prakadeshwari Rajapreyar
- Department of Pediatrics, Division of Critical Care Medicine, Medical College of Wisconsin, Milwaukee, WI
| | - Marie E. Steiner
- Department of Pediatrics, Divisions of Critical Care Medicine and Hematology/Oncology, University of Minnesota Medical School, Minneapolis, MN
| | - Leslie Lehmann
- Department of Pediatrics, Division of Hematology/Oncology, Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA
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Slooff V, Hoogendoorn R, Nielsen JSA, Pappachan J, Amigoni A, Caramelli F, Aziz O, Wildschut E, Verbruggen S, Crazzolara R, Dohna-Schwake C, Potratz J, Willems J, Llevadias J, Moscatelli A, Montaguti A, Bottari G, Di Nardo M, Schlapbach L, Wösten-van Asperen R. Role of extracorporeal membrane oxygenation in pediatric cancer patients: a systematic review and meta-analysis of observational studies. Ann Intensive Care 2022; 12:8. [PMID: 35092500 PMCID: PMC8800958 DOI: 10.1186/s13613-022-00983-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 01/13/2022] [Indexed: 01/10/2023] Open
Abstract
Background The use of extracorporeal membrane oxygenation (ECMO) in pediatric patients with underlying malignancies remains controversial. However, in an era in which the survival rates for children with malignancies have increased significantly and several recent reports have demonstrated effective ECMO use in children with cancer, we aimed to estimate the outcome and complications of ECMO treatment in these children. Methods We searched MEDLINE, Embase and CINAHL databases for studies on the use ECMO in pediatric patients with an underlying malignancy from inception to September 2020. This review was conducted in adherence to Preferred Reporting Items for Systematic Review and Meta-Analysis statement. Study eligibility was independently assessed by two authors and disagreements resolved by a third author. Included studies were evaluated for quality using the Newcastle–Ottawa Scale (NOS). Random effects meta-analyses (DerSimonian and Laird) were performed. The primary outcomes were mortality during ECMO or hospital mortality. Results Thirteen retrospective, observational cohort studies were included, most of moderate quality (625 patients). The commonest indication for ECMO was severe respiratory failure (92%). Pooled mortality during ECMO was 55% (95% confidence interval [CI], 47–63%) and pooled hospital mortality was 60% (95% CI 54–67%). Although heterogeneity among the included studies was low, confidence intervals were large. In addition, the majority of the data were derived from registries with overlapping patients which were excluded for the meta-analyses to prevent resampling of the same participants across the included studies. Finally, there was a lack of consistent complications reporting among the studies. Conclusion Significantly higher mortalities than in general PICU patients was reported with the use of ECMO in children with malignancies. Although these results need to be interpreted with caution due to the lack of granular data, they suggest that ECMO appears to represents a viable rescue option for selected patients with underlying malignancies. There is an urgent need for additional data to define patients for whom ECMO may provide benefit or harm. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-022-00983-0.
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Barreto JA, Mehta A, Thiagarajan RR, Hayward KN, Brogan A, Brogan TV. The Use of Extracorporeal Life Support in Children With Immune-Mediated Diseases. Pediatr Crit Care Med 2022; 23:e60-e65. [PMID: 34261943 DOI: 10.1097/pcc.0000000000002801] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To describe the use and outcomes of extracorporeal membrane oxygenation support among children with immune-mediated conditions. DESIGN Retrospective cohort study. SETTING The Extracorporeal Life Support Organization registry. PATIENTS Patients 1 month to 18 years old with International Classification of Diseases, 9th Edition and International Classification of Diseases, 10th Edition codes for immune-mediated conditions from 1989 to 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS During the study period, 207 patients with an immune-mediated condition received extracorporeal membrane oxygenation, and 50% survived to discharge. Most patients (63%) received extracorporeal membrane oxygenation for respiratory support with 53% survival, 21% received cardiac support (55% survival), and 15% received extracorporeal cardiopulmonary resuscitation (34% survival). The most common diagnosis among nonsurvivors was hemophagocytic lymphohistiocytosis/macrophage activation syndrome with 37% survival. Patients with juvenile idiopathic arthritis (23%) and dermatomyositis (25%) had the lowest survival. Nonsurvivors had a higher frequency of infections, neurologic complications, and renal replacement therapy use. Use of preextracorporeal membrane oxygenation corticosteroids was associated with mortality. CONCLUSIONS Children with immune-mediated conditions can be successfully supported with extracorporeal membrane oxygenation. Extracorporeal membrane oxygenation use has increased over time, and survival varies considerably by diagnosis.
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Affiliation(s)
- Jessica A Barreto
- Department of Pediatrics, Division of Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | - Amit Mehta
- Department of Pediatrics, Oregon Health and Sciences University, Portland, OR
| | - Ravi R Thiagarajan
- Department of Cardiology, Children's Hospital, Boston, Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Kristen N Hayward
- Department of Pediatrics, Division of Rheumatology, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
| | | | - Thomas V Brogan
- Department of Pediatrics, Division of Critical Care Medicine, Seattle Children's Hospital, University of Washington School of Medicine, Seattle, WA
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8
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ECMO Support in Pre-B-Cell ALL for Disseminated Legionnaire's Disease. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2021; 53:204-207. [PMID: 34658413 DOI: 10.1182/ject-2100020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 05/31/2021] [Indexed: 11/20/2022]
Abstract
Legionella pneumophila is a common cause of community- and hospital-acquired pneumonia. Its increasing frequency and reemergence as a pathogen of interest in the intensive care unit is likely due to increased awareness, recognition, and diagnostic test availability (1). Extracorporeal Membrane Oxygenation (ECMO) is increasingly used in the pediatric intensive care unit (PICU) for refractory cardiopulmonary failure and acute respiratory distress syndrome (ARDS) in concert with conventional modalities or when these have failed to adequately support the patient. The breadth of applications for this technology are ever-expanding as our collective knowledge and experience grows. With a particularly high mortality rate among immunocompromised patients, Legionnaires' disease should be considered early in the differential diagnosis and appropriate antimicrobials initiated (1). We present the case of an adolescent patient with pre-B-cell acute lymphoblastic leukemia (pre-B ALL) requiring ECMO support for septic shock and ARDS due to disseminated Legionella. To our knowledge, this is the first case describing an immunocompromised pediatric patient supported with ECMO for Legionnaires' disease.
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Bridges BC, Kilbaugh TJ, Barbaro RP, Bembea MM, Chima RS, Potera RM, Rosner EA, Sandhu HS, Slaven JE, Tarquinio KM, Cheifetz IM, Rowan CM, Friedman ML. Veno-Venous Extracorporeal Membrane Oxygenation for Children With Cancer or Hematopoietic Cell Transplant: A Ten Center Cohort. ASAIO J 2021; 67:923-929. [PMID: 33606393 PMCID: PMC8328899 DOI: 10.1097/mat.0000000000001336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
We performed a multicenter retrospective cohort study of children with 14 days to 18 years of age in the United States from 2011 to 2016 with cancer or hematopoietic cell transplant (HCT) who were supported with veno-venous extracorporeal membrane oxygenation (V-V ECMO). We compared the outcomes of children with oncological diagnoses or HCT supported with V-V ECMO to other children who have received V-V ECMO support. In this cohort of 204 patients supported with V-V ECMO, 30 (15%) had a diagnosis of cancer or a history of HCT. There were 21 patients who had oncological diagnoses without HCT and 9 children were post-HCT. The oncology/HCT group had a higher overall ICU mortality (67% vs. 28%, P < 0.001), mortality on ECMO (43% vs. 21%, P < 0.01), and ICU mortality among ECMO survivors (35% vs. 8%, P < 0.01). The oncology/HCT group had a higher rate of conversion to veno-arterial (V-A) ECMO (23% vs. 9%, P = 0.02) (RR, 2.5; 95% CI, 1.1-5.6). Children with cancer or HCT were older (6.6 vs. 2.9 years, P = 0.02) and had higher creatinine levels (0.65 vs. 0.4 mg/dL, P = 0.04) but were similar to the rest of the cohort for other pre-ECMO variables. For post-HCT patients, survival was significantly worse for those whose indication for HCT was cancer or immunodeficiency (0/6) as compared to other nonmalignant indications (3/3) (P = 0.01).
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Affiliation(s)
- Brian C. Bridges
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN
| | - Todd J. Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, The Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, PA
| | - Ryan P. Barbaro
- Department of Pediatrics, University of Michigan, Ann Arbor, MI
- Child Health Evaluation and Research Center, University of Michigan, Ann Arbor, MI
| | - Melania M. Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Ranjit S. Chima
- Department of Pediatrics, University of Cincinnati College of Medicine, Division of Critical Care Medicine, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Renee M. Potera
- Department of Pediatrics UT Southwestern Medical Center, Dallas, TX
| | - Elizabeth A. Rosner
- Division of Pediatric Critical Care Medicine, Helen DeVos Children’s Hospital, Grand Rapids, MI
| | - Hitesh S. Sandhu
- Division of Pediatric Critical Care, University of Tennessee Health Sciences Center, Memphis, TN
| | - James E. Slaven
- Department of Biostatistics, Indiana University School of Medicine, Indianapolis, IN
| | - Keiko M. Tarquinio
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Emory University, Children’s Healthcare of Atlanta, Atlanta, GA
| | - Ira M. Cheifetz
- Division of Cardiac Critical Care, University Hospitals Rainbow Babies and Children’s Hospital, Cleveland, OH
| | - Courtney M. Rowan
- Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University, Indianapolis, IN
| | - Matthew L. Friedman
- Division of Pediatric Critical Care, Riley Hospital for Children, Indiana University, Indianapolis, IN
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Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature. MEMBRANES 2021; 11:membranes11080584. [PMID: 34436348 PMCID: PMC8400963 DOI: 10.3390/membranes11080584] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/19/2021] [Accepted: 07/27/2021] [Indexed: 12/21/2022]
Abstract
(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.
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Abstract
PURPOSE OF REVIEW To review the indications for extra-corporeal membrane oxygenation (ECMO) in liver transplantation (LT) recipients and their optimal management on ECMO. RECENT FINDINGS Recent studies have reported a 30-40% survival rate among LT recipients that receive ECMO. Increasingly, case reports have documented successful outcomes of LT performed for patients on preoperative ECMO. Outcomes appear to be superior with patients in the immediate peri-LT period with reversible causes of severe, acute respiratory, and/or cardiovascular collapse. Mortality is most commonly secondary to infection. Volume optimization with CRRT may improve outcomes and perfusion to the graft, especially for patients on veno-arterial ECMO. There is little consensus on management of anticoagulation in these patients, but it can likely be held temporarily when the patient is coagulopathic and/or experiencing bleeding complications. SUMMARY ECMO should be considered in the peri-LT period for patients with severe, acute, and reversible causes of respiratory and/or cardiovascular collapse, with acceptable outcomes in patients that would otherwise not be expected to survive. Management of the post-LT patient on ECMO is challenging with a slowly enlarging body of literature to inform decision making.
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Affiliation(s)
- Rachel Hogen
- Division of Hepatobiliary and Abdominal Organ Transplant Surgery, Department of Surgery, University of Southern California, Los Angeles, CA
| | - Ashraf H. Sedra
- Department of Anesthesiology, University of Southern California, Los Angeles, CA
| | - Arash Motamed
- Department of Anesthesiology, University of Southern California, Los Angeles, CA
| | - Juliet Emamaullee
- Division of Hepatobiliary and Abdominal Organ Transplant Surgery, Department of Surgery, University of Southern California, Los Angeles, CA
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Potratz JC, Guddorf S, Ahlmann M, Tekaat M, Rossig C, Omran H, Masjosthusmann K, Groll AH. Extracorporeal Membrane Oxygenation in Children With Cancer or Hematopoietic Cell Transplantation: Single-Center Experience in 20 Consecutive Patients. Front Oncol 2021; 11:664928. [PMID: 33987100 PMCID: PMC8111086 DOI: 10.3389/fonc.2021.664928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 04/06/2021] [Indexed: 11/13/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a rescue therapy for severe respiratory and/or circulatory failure. Few data exist on the potential benefit of ECMO in immunocompromised pediatric patients with cancer and/or hematopoietic cell transplantation (HCT). Over a period of 12 years, eleven (1.9%) of 572 patients with new diagnosis of leukemia/lymphoma and nine (3.5%) of 257 patients post allogeneic HCT underwent ECMO at our center. Five (45%) and two (22%) patients, respectively, survived to hospital discharge with a median event-free survival of 4.2 years. Experiences and outcomes in this cohort may aid clinicians and families when considering ECMO for individual patients.
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Affiliation(s)
- Jenny C Potratz
- Department of General Pediatrics, University Children's Hospital Münster, Münster, Germany
| | - Sarah Guddorf
- Department of General Pediatrics, University Children's Hospital Münster, Münster, Germany
| | - Martina Ahlmann
- Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Maria Tekaat
- Department of General Pediatrics, University Children's Hospital Münster, Münster, Germany
| | - Claudia Rossig
- Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Heymut Omran
- Department of General Pediatrics, University Children's Hospital Münster, Münster, Germany
| | - Katja Masjosthusmann
- Department of General Pediatrics, University Children's Hospital Münster, Münster, Germany
| | - Andreas H Groll
- Department of Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
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13
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Olson TL, O'Neil ER, Kurtz KJ, MacLaren G, Anders MM. Improving Outcomes for Children Requiring Extracorporeal Membrane Oxygenation Therapy Following Hematopoietic Stem Cell Transplantation. Crit Care Med 2021; 49:e381-e393. [PMID: 33470779 DOI: 10.1097/ccm.0000000000004850] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
OBJECTIVES The objective of this study was to provide an updated review of survival for pediatric hematopoietic stem cell transplantation patients requiring extracorporeal membrane oxygenation therapy as well as characterize the demographics, clinical variables, and complications associated with mortality. DESIGN Retrospective database review of the Extracorporeal Life Support Organization Registry from 1990 to 2019. SETTING Extracorporeal membrane oxygenation centers reporting to Extracorporeal Life Support Organization. PATIENTS Patients treated with extracorporeal membrane oxygenation greater than 28 days to 18 years old with International Classification of Diseases Ninth Revision, International Classification of Diseases Tenth Revision, and current procedural terminology codes consistent with hematopoietic stem cell transplantation were included. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographics, year of extracorporeal membrane oxygenation run, clinical variables, comorbid diagnoses, and extracorporeal membrane oxygenation complications were assessed in relation to the primary study outcome of survival to hospital discharge. Ninety patients were included in the final analysis. The overall survival rate for the study period was 19%. However, the survival rate in the last decade (2010-2019) improved to 26% (p = 0.01; odds ratio 9.4 [1.2-74.8]). Factors associated with decreased survival included comorbid malignancy, elevated peak inspiratory pressure in conventionally ventilated patients, and pulmonary and metabolic complications on extracorporeal membrane oxygenation. CONCLUSIONS Pediatric patients posthematopoietic stem cell transplantation supported with extracorporeal membrane oxygenation have improving survival rates over time. With 26% of patients (16/62) surviving to hospital discharge in the last decade (2010-2019), history of hematopoietic stem cell transplantation may no longer be considered an absolute contraindication to extracorporeal membrane oxygenation. As advancements are made in hematopoietic stem cell transplantation therapies and extracorporeal membrane oxygenation management, the indications for life-saving extracorporeal membrane oxygenation support among patients posthematopoietic stem cell transplantation may expand accordingly.
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Affiliation(s)
- Taylor L Olson
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Erika R O'Neil
- Department of Pediatrics, Baylor College of Medicine, Houston, TX
| | - Kristen J Kurtz
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University Hospital, Singapore
- Paediatric Intensive Care Unit, Royal Children's Hospital, Melbourne, VIC, Australia
| | - Marc M Anders
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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Extracorporeal Membrane Oxygenation Support in Children With Hematologic Malignancies in Sweden. J Pediatr Hematol Oncol 2021; 43:e272-e275. [PMID: 32287104 DOI: 10.1097/mph.0000000000001808] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 03/23/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) is used in severe respiratory and/or circulatory failure when conventional critical care fails. Studies on patients with hematologic malignancies on ECMO have shown contradictory results; immunosuppression and coagulopathy are relative contraindications to ECMO. OBSERVATIONS This nationwide Swedish retrospective chart review identified 958 children with hematologic malignancies of whom 12 (1.3%) required ECMO support. Eight patients survived ECMO, 7 the total intensive care period, and 6 survived the underlying malignancy. CONCLUSIONS ECMO may be considered in children with hematologic malignancy. Short-term and long-term survival, in this limited group, was similar to that of children on ECMO at large.
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Use of Extracorporeal Membrane Oxygenation in Pneumocystis Pneumonia of an Infant with AIDS. Case Rep Pediatr 2020; 2020:8840131. [PMID: 33294246 PMCID: PMC7688365 DOI: 10.1155/2020/8840131] [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: 08/26/2020] [Accepted: 11/09/2020] [Indexed: 11/18/2022] Open
Abstract
Pneumocystis pneumonia is a common complication of cellular immunosuppression and may trigger severe pulmonary complications. Rapid onset of acquired immunodeficiency syndrome is possible in infants infected with human immunodeficiency virus (HIV). We report here the case of a 13-week-old girl who was previously healthy presenting with altered immunity and refractory acute respiratory distress syndrome (ARDS) initially attributed to bacterial pneumonia. Venovenous extracorporeal membrane oxygenation (VV-ECMO) was initiated because her condition was poor. An HIV infection was later fortuitously diagnosed after accidental exposure of a nurse to the child's urine. The mother had congenitally transmitted HIV to the child after late (undetected) infection during pregnancy. The lung lesions were finally attributed to Pneumocystis pneumonia. We prescribed combined antiretroviral, antibiotic, and steroid therapy aimed at preventing immune reconstitution inflammatory syndrome. VV-ECMO weaning progressed over 30 days to the time of decannulation, rapidly followed by extubation and hospital discharge. The case highlights the fact that rare curable causes of refractory pediatric ARDS should always be investigated early. VV-ECMO should not be excluded as an ARDS treatment for immunocompromised children.
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16
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Saito K, Aokage T, Sato T, Tsukahara K, Tokioka F, Otake T, Irie H, Ueda Y. Extracorporeal membrane oxygenation in Stenotrophomonas maltophilia pneumonia during acute myeloid leukemia: A case report. Respir Med Case Rep 2020; 31:101224. [PMID: 32995263 PMCID: PMC7502370 DOI: 10.1016/j.rmcr.2020.101224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2020] [Revised: 09/10/2020] [Accepted: 09/10/2020] [Indexed: 01/22/2023] Open
Abstract
Stenotrophomonas maltophilia (S. maltophilia) is a Gram-negative, multidrug-resistant organism that both opportunistically infects the bloodstream and leads to pneumonia in immunosuppressed patients, including those with hematologic malignancies. In patients with severe respiratory failure, venovenous extracorporeal membrane oxygenation (VV ECMO) can stabilize the respiratory status. However, whether ECMO in patients with hematologic malignancies improves the clinical outcomes is still controversial because ECMO increases the risk of the exacerbation of sepsis and bleeding. We report a case of a 46-year-old man with Stenotrophomonas maltophilia hemorrhagic pneumonia acquired during consolidation chemotherapy for acute myeloid leukemia in whom VV ECMO lead to a good clinical outcome. The stabilization of his respiratory status achieved with VV ECMO allowed time for trimethoprim-sulfamethoxazole antibiotic therapy to improve the pneumonia. We suggest the background of patients, including comorbidities and general conditions, should be taken into account when considering the clinical indications of ECMO.
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Affiliation(s)
- Kenki Saito
- Department of Hematology/Oncology, Kurashiki Central Hospital, Japan
| | - Toshiyuki Aokage
- Department of Geriatric Emergency Medicine, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan
| | - Takayuki Sato
- Department of Hematology/Oncology, Kurashiki Central Hospital, Japan
| | - Kohei Tsukahara
- Department of Emergency, Critical Care and Disaster Medicine, Okayama University Hospital, Okayama, Japan
| | - Fumiaki Tokioka
- Department of Respiratory Medicine, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takanao Otake
- Department of Anesthesiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hiromasa Irie
- Department of Anesthesiology, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yasunori Ueda
- Department of Hematology/Oncology, Kurashiki Central Hospital, Japan
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17
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Extracorporeal Membrane Oxygenation Mortality in High-Risk Populations: An Analysis of the Pediatric Health Information System Database. ASAIO J 2020; 66:327-331. [DOI: 10.1097/mat.0000000000001002] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
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18
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Erickson S. Extra-corporeal membrane oxygenation in paediatric acute respiratory distress syndrome: overrated or underutilized? ANNALS OF TRANSLATIONAL MEDICINE 2019; 7:512. [PMID: 31728365 DOI: 10.21037/atm.2019.09.27] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a modified form of cardiopulmonary bypass which may provide support for severe cardiorespiratory failure including paediatric acute respiratory distress syndrome (PARDS). While ECMO was initially demonstrated to successfully support neonates with severe respiratory failure, the use of ECMO has expanded rapidly to support both paediatric and adult respiratory failure. Extracorporeal Life Support Organization (ELSO) registry data shows that the use of ECMO for paediatric respiratory failure has expanded rapidly over the past decades with increasing use of venovenous ECMO. Despite the increasing complexity of children supported by ECMO for ARDS, outcomes have remained consistent with survival to hospital discharge greater than 50%. ECMO complications are still common and potentially devastating, especially neurological complications. There is grade 1 evidence to support the use of ECMO in both neonatal and adult respiratory failure but evidence in paediatric respiratory failure is confined to case series and case-control studies. While there are no published guidelines for use of ECMO in PARDS, in particular no clearly defined inclusion and exclusion criteria, current evidence suggests that children with severe ARDS may benefit from ECMO support, with survival to hospital discharge equivalent or better than conventional management in children with severe ARDS.
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Affiliation(s)
- Simon Erickson
- Paediatric Critical Care, Perth Children's Hospital, Nedlands, Western Australia, Australia.,Senior Lecturer, University of Western Australia, Hackett Drive, Nedlands, Western Australia, Australia
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19
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Yehya N, Thomas NJ. Sepsis and Pediatric Acute Respiratory Distress Syndrome. J Pediatr Intensive Care 2018; 8:32-41. [PMID: 31073506 DOI: 10.1055/s-0038-1676133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 10/17/2018] [Indexed: 12/13/2022] Open
Abstract
The epidemiology of the acute respiratory distress syndrome (ARDS) in pediatric sepsis is poorly defined. With significant data extrapolated from adult studies in sepsis and ARDS, sometimes with uncertain applicability, better pediatric-specific guidelines and dedicated investigations are warranted. The recent publication of a consensus definition for pediatric ARDS (PARDS) is the first step in addressing this knowledge gap. The aim of this review is to frame our current understanding of PARDS as it relates to pediatric sepsis, encompassing epidemiology, pathophysiology, and management. We argue that addressing the role of PARDS in pediatric sepsis requires significant attention to details with respect to how PARDS and sepsis are defined to accurately describe their epidemiology, natural history, and outcomes. Finally, we highlight certain aspects of PARDS management as they relate to the septic child and offer suggestion for future directions in this field.
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Affiliation(s)
- Nadir Yehya
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and University of Pennsylvania, Philadelphia, Pennsylvania, United States
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Department of Pediatrics and Public Health Science, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, United States
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20
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Potratz J, Ahlmann M, Rössig C, Omran H, Masjosthusmann K. Successful Extracorporeal Life Support in a Pediatric Hematopoietic Stem Cell Transplant Recipient With Periengraftment Respiratory Failure. J Pediatr Hematol Oncol 2018; 40:e256-e259. [PMID: 28816799 DOI: 10.1097/mph.0000000000000929] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
The use of extracorporeal life support (ECLS) as ultimate salvage therapy for hematopoietic stem cell transplant recipients remains controversial among oncologists and critical care specialists. Prognosis is poor, particularly after allogeneic transplantation, and literature to guide clinical decision-making is scarce. Our report describes successful ECLS in a pediatric patient undergoing allogeneic hematopoietic stem cell transplantation, who developed acute respiratory failure during severe neutropenia, followed by immediate neutrophil engraftment. This unique case highlights periengraftment respiratory failure as a possible patient subgroup that could benefit from ECLS; and illustrates that the distinct etiologies of respiratory failure and the patients' immune status deserve closer consideration in future studies evaluating ECLS in this high-risk population.
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Affiliation(s)
- Jenny Potratz
- Departments of General Pediatrics-Intensive Care Medicine
| | - Martina Ahlmann
- Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Claudia Rössig
- Pediatric Hematology and Oncology, University Children's Hospital Münster, Münster, Germany
| | - Heymut Omran
- Departments of General Pediatrics-Intensive Care Medicine
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21
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Bembea MM, Hoskote A, Guerguerian AM. Pediatric ECMO Research: The Case for Collaboration. Front Pediatr 2018; 6:240. [PMID: 30250837 PMCID: PMC6139332 DOI: 10.3389/fped.2018.00240] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 08/13/2018] [Indexed: 12/14/2022] Open
Abstract
The use of extracorporeal membrane oxygenation (ECMO) in the pediatric age has increased considerably in the last decade, as has the complexity of cases and the variety of indications outside of the neonatal age. However, no randomized controlled trials have been attempted to date to test ECMO as an intervention in non-neonatal pediatric patients with critical illness. In this review, we provide a brief overview of the history of clinical research in pediatric ECMO and discuss methodological challenges including heterogeneity of ages and diagnoses in the pediatric ECMO population, rapid advances in technology and clinical practice related to ECMO, feasibility of enrolling critically ill children on ECMO in clinical research studies, and variability in ECMO management across institutions and countries. Lastly, we discuss opportunities and existing infrastructure for future multicenter, multi-network research collaborations for pediatric ECMO studies.
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Affiliation(s)
- Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Aparna Hoskote
- Cardiorespiratory and Critical Care Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Anne-Marie Guerguerian
- Department of Critical Care Medicine, Hospital for Sick Children and University of Toronto, Toronto, ON, Canada
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22
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Abe M, Ide K, Nishimura N, Nakagawa S, Fukuda A, Sakamoto S, Kasahara M. Successful venoarterial extracorporeal membrane oxygenation for postoperative septic shock in a child with liver transplantation: A case report. Pediatr Transplant 2017; 21. [PMID: 28901029 DOI: 10.1111/petr.13063] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/17/2017] [Indexed: 11/29/2022]
Abstract
Refractory septic shock after LT is a life-threatening complication. VA ECMO is used to treat refractory cardiorespiratory failure. We present herein the case of a 5-year-old girl with post-Kasai biliary atresia, who underwent a living donor LT and suffered refractory septic shock. VA ECMO was indicated due to progressive cardiac deterioration. After full recovery of her EF, she has been steadily improving and has shown good liver function and no neurological sequelae. This is the first report of successful VA ECMO in a post- LT patient with refractory septic shock.
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Affiliation(s)
- Michiko Abe
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Kentaro Ide
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Nao Nishimura
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Satoshi Nakagawa
- Critical Care Medicine, National Center for Child Health and Development, Tokyo, Japan
| | - Akinari Fukuda
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Seisuke Sakamoto
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
| | - Mureo Kasahara
- Organ Transplantation Center, National Center for Child Health and Development, Tokyo, Japan
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24
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Rambaud J, Guilbert J, Guellec I, Jean S, Durandy A, Demoulin M, Amblard A, Carbajal R, Leger PL. [Extracorporeal membrane oxygenation in critically ill neonates and children]. Arch Pediatr 2017; 24:578-586. [PMID: 28416430 DOI: 10.1016/j.arcped.2017.03.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Revised: 01/02/2017] [Accepted: 03/11/2017] [Indexed: 10/19/2022]
Abstract
Extracorporeal membrane oxygenation is used as a last resort during neonatal and pediatric resuscitation in case of refractory circulatory or respiratory failure under maximum conventional therapies. Different types of ECMO can be used depending on the initial failure. The main indications for ECMO are refractory respiratory failure (acute respiratory distress syndrome, status asthmaticus, severe pneumonia, meconium aspiration syndrome, pulmonary hypertension) and refractory circulatory failure (cardiogenic shock, septic shock, refractory cardiac arrest). The main contraindications are a gestational age under 34 weeks or birth weight under 2kg, severe underlying pulmonary disease, severe immune deficiency, a neurodegenerative disease and hereditary disease of hemostasis. Neurological impairment can occur during ECMO (cranial hemorrhage, seizure or stroke). Nosocomial infections and acute kidney injury are also frequent complications of ECMO. The overall survival rate of ECMO is about 60 %. This survival rate can change depending on the initial disease: from 80 % for meconium aspiration syndrome to less than 10 % for out-of-hospital refractory cardiac arrest. Recently, mobile ECMO units have been created. These units are able to perform ECMO out of a referral center for untransportable critically ill patients.
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Affiliation(s)
- J Rambaud
- Service de réanimation néonatale et pédiatrique, CHU d'Armand-Trousseau, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France; Université Pierre et Marie Curie (UPMC), 75005 Paris, France.
| | - J Guilbert
- Service de réanimation néonatale et pédiatrique, CHU d'Armand-Trousseau, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France
| | - I Guellec
- Service de réanimation néonatale et pédiatrique, CHU d'Armand-Trousseau, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France
| | - S Jean
- Service de réanimation néonatale et pédiatrique, CHU d'Armand-Trousseau, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France
| | - A Durandy
- Service de réanimation néonatale et pédiatrique, CHU d'Armand-Trousseau, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France; Université Pierre et Marie Curie (UPMC), 75005 Paris, France
| | - M Demoulin
- Service de réanimation néonatale et pédiatrique, CHU d'Armand-Trousseau, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France; Université Pierre et Marie Curie (UPMC), 75005 Paris, France
| | - A Amblard
- Service de réanimation néonatale et pédiatrique, CHU d'Armand-Trousseau, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France
| | - R Carbajal
- Service de réanimation néonatale et pédiatrique, CHU d'Armand-Trousseau, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France
| | - P-L Leger
- Service de réanimation néonatale et pédiatrique, CHU d'Armand-Trousseau, 26, avenue du Dr-Arnold-Netter, 75012 Paris, France; Unité Inserm U1141, hôpital Robert-Debré, 75019 Paris, France
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Abstract
Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) is a form of heart lung bypass that is used to support neonates, pediatrics, and adult patients with cardiorespiratory failure for days or weeks till organ recovery or transplantation. Venoarterial (VA) and venovenous (VV) ECLS are the most common modes of support. ECLS circuit components and monitoring have been evolving over the last 40 years. The technology is safer, simpler, and more durable with fewer complications. The use of neonatal respiratory ECLS use has been declining over the last two decades, while adult respiratory ECLS is growing especially since the H1N1 influenza pandemic in 2009. This review provides an overview of ECLS evolution over the last four decades, its use in neonatal, pediatric and adults, description of basic principles, circuit components, complications, and outcomes as well as a quick look into the future.
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26
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Kuo KW, Barbaro RP, Gadepalli SK, Davis MM, Bartlett RH, Odetola FO. Should Extracorporeal Membrane Oxygenation Be Offered? An International Survey. J Pediatr 2017; 182:107-113. [PMID: 28041665 DOI: 10.1016/j.jpeds.2016.12.025] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Revised: 10/26/2016] [Accepted: 12/07/2016] [Indexed: 01/19/2023]
Abstract
OBJECTIVES To assess the current attitudes of extracorporeal membrane oxygenation (ECMO) program directors regarding eligibility for ECMO among children with cardiopulmonary failure. STUDY DESIGN Electronic cross-sectional survey of ECMO program directors at ECMO centers worldwide within the Extracorporeal Life Support Organization directory (October 2015-December 2015). RESULTS Of 733 eligible respondents, 226 (31%) completed the survey, 65% of whom routinely cared for pediatric patients. There was wide variability in whether respondents would offer ECMO to any of the 5 scenario patients, ranging from 31% who would offer ECMO to a child with trisomy 18 to 76% who would offer ECMO to a child with prolonged cardiac arrest and indeterminate neurologic status. Even physicians practicing the same specialty sometimes held widely divergent opinions, with 50% of pediatric intensivists stating they would offer ECMO to a child with severe developmental delay and 50% stating they would not. Factors such as quality of life and neurologic status influenced decision making and were used to support decisions for and against offering ECMO. CONCLUSIONS ECMO program directors vary widely in whether they would offer ECMO to various children with cardiopulmonary failure. This heterogeneity in physician decision making underscores the need for more evidence that could eventually inform interinstitutional guidelines regarding patient selection for ECMO.
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Affiliation(s)
- Kevin W Kuo
- Division of Pediatric Critical Care, Department of Pediatrics, University of Michigan, Ann Arbor, MI.
| | - Ryan P Barbaro
- Division of Pediatric Critical Care, Department of Pediatrics, University of Michigan, Ann Arbor, MI
| | | | - Matthew M Davis
- Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, IL
| | | | - Folafoluwa O Odetola
- Division of Pediatric Critical Care, Department of Pediatrics, University of Michigan, Ann Arbor, MI
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Cashen K, Chu RL, Klein J, Rycus PT, Costello JM. Extracorporeal membrane oxygenation outcomes in children with hemophagocytic lymphohistiocytosis. Perfusion 2016; 32:151-156. [PMID: 27625333 DOI: 10.1177/0267659116667804] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION Pediatric patients with hemophagocytic lymphohistiocytosis (HLH) may develop refractory respiratory or cardiac failure that warrants consideration for extracorporeal membrane oxygenation (ECMO) support. The purposes of this study were to describe the use and outcomes of ECMO in pediatric HLH patients, to identify risk factors for hospital mortality and to compare their ECMO use and outcomes to the ECMO population as a whole. METHODS Pediatric patients (⩽ 18 years) with a diagnosis of HLH in the Extracorporeal Life Support Organization (ELSO) Registry were included. RESULTS Between 1983 and 2014, data for 30 children with HLH were available in the ELSO registry and all were included in this study. All cases occurred in the last decade. Of the 30 HLH patients, 24 (80%) had a respiratory indication for ECMO and six (20%) had a cardiac indication (of which 4 were E-CPR and 2 cardiac failure). Of the 24 respiratory ECMO patients, 63% were placed on VA ECMO. Compared with all pediatric patients in the ELSO registry during the study period (n=17,007), HLH patients had worse hospital survival (non-HLH 59% vs HLH 30%, p=0.001). In pediatric HLH patients, no pre-ECMO risk factors for mortality were identified. The development of a hemorrhagic complication on ECMO was associated with decreased mortality (p=0.01). Comparing HLH patients with respiratory failure to patients with other immune compromised conditions, the overall survival rate is similar (HLH 38% vs. non-HLH immune compromised 31%, p=0.64). CONCLUSIONS HLH is an uncommon indication for ECMO and these patients have increased mortality compared to the overall pediatric ECMO population. These data should be factored into decision-making when considering ECMO for pediatric HLH patients.
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Affiliation(s)
- Katherine Cashen
- 1 Divisions of Critical Care and Hematology Oncology, Department of Pediatrics, Children's Hospital of Michigan/Wayne State University School of Medicine, Detroit, MI, USA
| | - Roland L Chu
- 1 Divisions of Critical Care and Hematology Oncology, Department of Pediatrics, Children's Hospital of Michigan/Wayne State University School of Medicine, Detroit, MI, USA
| | - Justin Klein
- 2 Department of Pediatric Surgery, Children's Hospital of Michigan/Wayne State University School of Medicine, Detroit, MI, USA
| | - Peter T Rycus
- 3 Extracorporeal Life Support Organization, Ann Arbor, MI, USA
| | - John M Costello
- 4 Divisions of Cardiology and Critical Care Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago/Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Sanford E, Wolbrink T, Mack J, Rowe RG. Severe Tumor Lysis Syndrome and Acute Pulmonary Edema Requiring Extracorporeal Membrane Oxygenation Following Initiation of Chemotherapy for Metastatic Alveolar Rhabdomyosarcoma. Pediatr Blood Cancer 2016; 63:928-30. [PMID: 26713672 PMCID: PMC5849391 DOI: 10.1002/pbc.25879] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2015] [Revised: 11/24/2015] [Accepted: 11/28/2015] [Indexed: 11/10/2022]
Abstract
We present an 8-year-old male with metastatic alveolar rhabdomyosarcoma (ARMS) who developed precipitous cardiopulmonary collapse with severe tumor lysis syndrome (TLS) 48 hr after initiation of chemotherapy. Despite no detectable pulmonary metastases, acute hypoxemic respiratory failure developed, requiring extracorporeal membrane oxygenation (ECMO). Although TLS has been reported in disseminated ARMS, this singular case of life-threatening respiratory deterioration developing after initiation of chemotherapy presented unique therapeutic dilemmas. We review the clinical aspects of this case, including possible mechanisms of respiratory failure, and discuss the role of ECMO utilization in pediatric oncology.
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Affiliation(s)
- Ethan Sanford
- Department of Pediatrics, Boston Children’s Hospital, Boston, Massachusetts
- Department of Anesthesiology, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Traci Wolbrink
- Department of Anesthesia and Critical Care Medicine, Boston Children’s Hospital, Boston, Massachusetts
| | - Jennifer Mack
- Dana-Farber Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts
| | - R. Grant Rowe
- Dana-Farber Boston Children’s Cancer and Blood Disorders Center, Boston, Massachusetts
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Dioverti MV, Cawcutt KA, Schears GJ, Baddour LM. Use of Extracorporeal Membrane Oxygenation for the Treatment of Influenza-Induced Acute Respiratory Distress Syndrome in Immunocompromised Adults. Am J Med Sci 2016; 352:81-5. [PMID: 27432039 DOI: 10.1016/j.amjms.2016.03.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 02/23/2016] [Accepted: 03/22/2016] [Indexed: 11/28/2022]
Abstract
Influenza infection in the adult immunocompromised hosts can have severe presentations and rapid progression to lower respiratory tract infection requiring mechanical ventilation, and it even can progress to acute respiratory distress syndrome. Little is known about the role of extracorporeal membrane oxygenation for management in this setting. We present a review of the current literature on the subject.
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Affiliation(s)
| | - Kelly A Cawcutt
- Division of Infectious Disease, Mayo Clinic, Rochester, Minnesota
| | | | - Larry M Baddour
- Division of Infectious Disease, Mayo Clinic, Rochester, Minnesota
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Schmidt M, Bréchot N, Combes A. Ten situations in which ECMO is unlikely to be successful. Intensive Care Med 2015; 42:750-752. [PMID: 26271905 DOI: 10.1007/s00134-015-4013-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Accepted: 08/05/2015] [Indexed: 01/08/2023]
Affiliation(s)
- Matthieu Schmidt
- Service de Réanimation Médicale, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France.
| | - Nicolas Bréchot
- Service de Réanimation Médicale, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France
| | - Alain Combes
- Service de Réanimation Médicale, iCAN, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, 47, bd de l'Hôpital, 75651, Paris Cedex 13, France
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[Extracorporeal membrane oxygenation in children]. Med Klin Intensivmed Notfmed 2015; 110:438-44. [PMID: 26267893 DOI: 10.1007/s00063-015-0062-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2015] [Accepted: 07/13/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Children who require mechanical ventilation represent a high-risk population with significant morbidity and mortality. Experienced handling of conventional therapies including high frequency oscillation ventilation and initiation of newer treatment options such as surfactant or nitric oxide has led to some improvements. Nevertheless, extracorporeal membrane oxygenation (ECMO) is a life-saving technology in patients with respiratory failure refractory to maximal medical therapy. OBJECTIVE This article shows the therapeutic management and the selection criteria for ECMO in neonates and children based on the clinical signs of acquired and congenital diseases that can lead to respiratory failure. RESULTS The distribution of diagnoses, survival rates, and demographic change of ECMO in newborns since the beginning of documentation in 1986 by the Extracorporeal Life Support Organization (ELSO) registry and the largest German ECMO Center Mannheim are described. Despite a changed diagnostic distribution in the direction of congenital pulmonary disease, the survival rate of ECMO in the neonates has remained well above 70 %. In pediatric ECMO, the survival rate has also remained constant despite a more complex patient population. The highest values are seen in the youngest patients without underlying disease. CONCLUSION Despite limited evidence and relatively few randomized trials in children, ECMO remains the safety net for patients with severe respiratory failure. Experience as measured by the annual number of cases plays an important role for the quality of results.
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Kang HS, Rhee CK, Lee HY, Kim YK, Kwon SS, Kim SC, Lee JW. Clinical outcomes of extracorporeal membrane oxygenation support in patients with hematologic malignancies. Korean J Intern Med 2015; 30:478-88. [PMID: 26161014 PMCID: PMC4497335 DOI: 10.3904/kjim.2015.30.4.478] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 06/23/2014] [Accepted: 09/01/2014] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND/AIMS The clinical outcomes of patients with hematologic malignancies who were treated with extracorporeal membrane oxygenation (ECMO) after the failu re of optimal conventional therapy were determined. METHODS The medical records of all patients administered ECMO during their stay in a medical intensive care unit of Seoul St. Mary's Hospital between February 2010 and July 2013 were reviewed retrospectively. RESULTS In total, 15 patients with hematologic malignancies were compared to 33 immunocompetent patients with documented cardiorespiratory failure. Underlying hematologic malignancies were significantly associated with lower overall survival (0.0% vs. 24.2%, p = 0.044). Mortality was significantly associated with a higher 24 hours ECMO inspired fraction of oxygen (0.71 ± 0.24 vs. 0.47 ± 0.13, p = 0.015), the development of infection after ECMO (87.5% vs. 25.0%, p = 0.001), and the presence of hyperbilirubinemia (70.0% vs. 0.0%, p < 0.001). Matching of the patients based on their Acute Physiology and Chronic Health Evaluation II scores confirmed the greater risk of mortality in patients with hematologic malignancies (survival: 0.0% vs. 40.0%, p = 0.017). The mean difference in inotropic-equivalent scores after ECMO was significantly lower in the immunocompetent patients than in those with hematologic malignancies (-59.22 ± 97.83 vs. 53.87 ± 164.46, p = 0.026). CONCLUSIONS Patients with hematologic malignancies who require ECMO for respiratory support have poor outcomes. The incidence of complications in these patients did not significantly differ from that in immunocompetent patients.
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Affiliation(s)
- Hye Seon Kang
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Chin Kook Rhee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Hea Yon Lee
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Kyoon Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Soon Seog Kwon
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Seok Chan Kim
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong Wook Lee
- Division of Hematology, Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Aokage T, Palmér K, Ichiba S, Takeda S. Extracorporeal membrane oxygenation for acute respiratory distress syndrome. J Intensive Care 2015; 3:17. [PMID: 27408728 PMCID: PMC4940971 DOI: 10.1186/s40560-015-0082-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2015] [Accepted: 03/10/2015] [Indexed: 01/11/2023] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) can be a lifesaving therapy in patients with refractory severe respiratory failure or cardiac failure. Severe acute respiratory distress syndrome (ARDS) still has a high-mortality rate, but ECMO may be able to improve the outcome. Use of ECMO for respiratory failure has been increasing since 2009. Initiation of ECMO for adult ARDS should be considered when conventional therapy cannot maintain adequate oxygenation. ECMO can stabilize gas exchange and haemodynamic compromise, consequently preventing further hypoxic organ damage. ECMO is not a treatment for the underlying cause of ARDS. Because ARDS has multiple causes, the diagnosis should be investigated and treatment should be commenced during ECMO. Since ECMO is a complicated and high-risk therapy, adequate training in its performance and creation of a referring hospital network are essential. ECMO transport may be an effective method of transferring patients with severe ARDS.
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Affiliation(s)
- Toshiyuki Aokage
- ECMO Centre Karolinska, Astrid Lindgren Children's Hospital, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Kenneth Palmér
- ECMO Centre Karolinska, Astrid Lindgren Children's Hospital, Karolinska University Hospital, 17176 Stockholm, Sweden
| | - Shingo Ichiba
- Department of Community and Emergency Medicine, Okayama University Graduate School of Medicine, Dentistry, and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Kita-ku, Okayama 700-8558 Japan
| | - Shinhiro Takeda
- Department of Intensive Care Medicine, Nippon Medical School Hospital, 1-1-5 Sendagi, Bunkyo-ku, Tokyo 113-8603 Japan
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Successful Use of Extracorporeal Membrane Oxygenation for Respiratory Failure in Pulmonary Chronic Graft-Versus-Host Disease. ASAIO J 2014; 60:122-3. [DOI: 10.1097/mat.0000000000000016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure: an evidence-based review of the past decade (2002-2012). Pediatr Crit Care Med 2013; 14:851-61. [PMID: 24108118 DOI: 10.1097/pcc.0b013e3182a5540d] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To provide a comprehensive evidence-based review of extracorporeal membrane oxygenation for neonatal and pediatric respiratory failure. DATA SOURCE A thorough computerized bibliographic search of the clinical literature regarding the use of extracorporeal membrane oxygenation in the neonatal and pediatric populations. STUDY SELECTION Clinical trials published between January 1, 2002, and October 1, 2012, including "extracorporeal membrane oxygenation" or "ECMO" and limited to studies involving humans aged 0-18 years. Trials focused on extracorporeal membrane oxygenation for cardiac indications were excluded from this study, unless the study was evaluating ancillary therapies in conjunction with extracorporeal membrane oxygenation. DATA EXTRACTION Studies were evaluated for inclusion based on reporting of patient outcomes and/or strategic considerations, such as cannulation strategies, timing of extracorporeal membrane oxygenation utilization, and ancillary therapies. DATA SYNTHESIS Pertinent data are summarized, and the available data are objectively classified based on the value of the study design from which the data are obtained. CONCLUSIONS Despite a large number of published extracorporeal membrane oxygenation studies, there remains a paucity of high-quality clinical trials. The available data support continued use of extracorporeal membrane oxygenation for respiratory failure refractory to conventional therapy for neonatal and pediatric patients without significant comorbidities. Further research is needed to better quantify the benefit of extracorporeal membrane oxygenation and the utility of many therapies commonly applied to extracorporeal membrane oxygenation patients.
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36
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Renolleau S. [Particularities of ECMO in acute respiratory distress syndrome in pediatrics]. MEDECINE INTENSIVE REANIMATION 2013; 22:654-662. [PMID: 32288736 PMCID: PMC7117835 DOI: 10.1007/s13546-014-0876-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Les techniques de circulation extracorporelle sont utilisées en pédiatrie dans les syndromes de détresse respiratoire aiguë (SDRA) les plus graves depuis les années 1980. Les données du registre international de l’Extracorporeal Life Support Organization révèlent plus 5 000 enfants placés en extracorporeal membrane oxygenation (ECMO) en 2012 avec une augmentation du nombre de cas annuels depuis l’épidémie de 2009. La survie, de 56 %, est stable alors que le nombre d’enfants avec des comorbidités augmente grâce aux améliorations apportées au matériel. Bien que nous ne disposions pas d’études randomisées, ces résultats encouragent à proposer l’ECMO dans l’arsenal thérapeutique du SDRA de l’enfant. Si les techniques veinoveineuses doivent être privilégiées dans les affections respiratoires, l’ECMO veinoartérielle peut être nécessaire et reste d’une utilisation fréquente chez l’enfant (50 % des cas). En pédiatrie, les particularités techniques sont liées d’une part aux particularités physiologiques de l’enfant et d’autre part aux contraintes dues au matériel proposé selon les différentes catégories d’âge. L’ECMO est une technique de recours lourde qui nécessite une expertise à la fois technique et pédiatrique spécialisée en raison de ce terrain particulier.
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Affiliation(s)
- S Renolleau
- Service de réanimation néonatale et pédiatrique, groupe hospitalier Armand-Trousseau-La-Roche-Guyon, AP-HP, université Pierre-et-Marie-Curie-Paris-VI, 26, avenue du Docteur-Arnold-Netter, F-75012 Paris, France
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Hanke SP, Gardner AB, Lombardi JP, Manning PB, Nelson DP, Towbin JA, Jefferies JL, Lorts A. Left ventricular noncompaction cardiomyopathy in Barth syndrome: an example of an undulating cardiac phenotype necessitating mechanical circulatory support as a bridge to transplantation. Pediatr Cardiol 2012; 33:1430-4. [PMID: 22427193 DOI: 10.1007/s00246-012-0258-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2011] [Accepted: 02/16/2012] [Indexed: 12/12/2022]
Abstract
Barth syndrome (BTHS) is associated with myocardial disease, frequently left ventricular noncompaction cardiomyopathy, which may necessitate cardiac transplantation or lead to death in some patients. We report a child with BTHS who had an "undulating cardiac phenotype" and ultimately developed decompensated heart failure requiring mechanical circulatory support with a ventricular assist device as a bridge to transplantation. His course was complicated by acute lung injury requiring placement of an in-line oxygenator to maintain end-organ function. Not only was his course complicated by cardiac and respiratory failure but his BTHS associated comorbidities complicated the management of his therapy using mechanical assist device support. He was successfully supported and subsequently was transplanted. Here we discuss the management of a child with BTHS using mechanical circulatory support and describe the use of an in-line oxygenator, Quadrox, with the Berlin Excor device.
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Affiliation(s)
- Samuel P Hanke
- Heart Institute, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue-ML 2003, Cincinnati, OH 45213, USA
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One is not zero. Pediatr Crit Care Med 2012; 13:609-10. [PMID: 22955467 DOI: 10.1097/pcc.0b013e31825b54c5] [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: 11/26/2022]
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Madden JL, Schober ME, Meyers RL, Bratton SL, Holland SM, Hill HR, Rollins MD. Successful use of extracorporeal membrane oxygenation for acute respiratory failure in a patient with chronic granulomatous disease. J Pediatr Surg 2012; 47:E21-3. [PMID: 22595605 PMCID: PMC4103901 DOI: 10.1016/j.jpedsurg.2011.12.029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2011] [Revised: 11/23/2011] [Accepted: 12/29/2011] [Indexed: 10/28/2022]
Abstract
A 9-year-old boy presented with pneumonia, bilateral pulmonary lesions, and fulminant respiratory failure requiring support with extracorporeal membrane oxygenation (ECMO). Open lung biopsy and subsequent bronchoscopy identified Nocardia cyriacigeorgica and Burkholderia cepacia pneumonia. Chronic granulomatous disease (CGD) was diagnosed by an abnormal neutrophil oxidative burst assay. An aggressive diagnostic and therapeutic strategy, which included ECMO, allowed for patient survival and return to baseline function. No ECMO survivors with CGD have previously been reported. It is now recognized that several forms of CGD exist, and some forms may be compatible with long-term survival. Therefore, the diagnosis of CGD should not necessarily be considered a contraindication to ECMO. This is the first known survivor of CGD-related acute respiratory failure supported by ECMO.
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Affiliation(s)
- Jesse L. Madden
- Department of Surgery, Primary Children’s Medical Center, Salt Lake City, UT, USA,Corresponding author. University of Utah, Primary Children’s Medical Center, Salt Lake City, UT, USA
| | - Michelle E. Schober
- Division of Critical Care, Department of Pediatrics, Primary Children’s Medical Center, Salt Lake City, UT, USA
| | - Rebecka L. Meyers
- Division of Pediatric Surgery, Primary Children’s Medical Center, Salt Lake City, UT, USA
| | - Susan L. Bratton
- Division of Critical Care, Department of Pediatrics, Primary Children’s Medical Center, Salt Lake City, UT, USA
| | - Steven M. Holland
- Laboratory of Clinical Infectious Diseases, NIAID, National Institute of Health, Bethesda, MD, USA
| | - Harry R. Hill
- Departments of Pathology, Pediatrics, and Medicine, University of Utah and ARUP Institute for Clinical and Experimental Pathology, Salt Lake City, UT, USA
| | - Michael D. Rollins
- Division of Pediatric Surgery, Primary Children’s Medical Center, Salt Lake City, UT, USA
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The impact of mechanical ventilation time before initiation of extracorporeal life support on survival in pediatric respiratory failure: a review of the Extracorporeal Life Support Registry. Pediatr Crit Care Med 2012; 13:16-21. [PMID: 21478791 DOI: 10.1097/pcc.0b013e3182192c66] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the relationship between duration of mechanical ventilation before the initiation of extracorporeal life support and the survival rate in children with respiratory failure. Extracorporeal life support has been used as a rescue therapy for >30 yrs in children with severe respiratory failure. Previous studies suggest patients who received >7-10 days of mechanical ventilation were not acceptable extracorporeal life support candidates as a result of irreversible lung damage. DESIGN A retrospective review encompassing the past 10 yrs of the International Extracorporeal Life Support Organization Registry (January 1, 1999, to December 31, 2008). SETTING Extracorporeal Life Support Organization Registry database. PATIENTS A total of 1325 children (≥ 30 days and ≤ 18 yrs) met inclusion criteria. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The following pre-extracorporeal life support variables were identified as independently and significantly related to the chance of survival: 1) >14 days of ventilation vs. 0-7 days was adverse (odds ratio, 0.32; p < .001); 2) the presence of a cardiac arrest was adverse (odds ratio, 0.56; p = .001); 3) pH per 0.1-unit increase was protective (odds ratio, 1.15; p < .001); 4) oxygenation index, per 10-unit increase was adverse (odds ratio, 0.95; p = .002); and 5) any diagnosis other than sepsis was related to a more favorable outcome. Patients requiring >7-10 or >10-14 days of pre-extracorporeal life support ventilation did not have a statistically significant decrease in survival as compared with patients who received 0-7 days. CONCLUSIONS There was a clear relationship between the number of mechanical ventilation days before the initiation of extracorporeal life support and survival. However; there was no statistically significant decrease in survival until >14 days of pre-extracorporeal life support ventilation was reached regardless of underlying diagnosis. We found no evidence to suggest that prolonged mechanical ventilation should be considered as a contraindication to extracorporeal life support in children with respiratory failure before 14 days.
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41
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Extrakorporale Membranoxygenierung (ECMO). Monatsschr Kinderheilkd 2011. [DOI: 10.1007/s00112-011-2421-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Glial fibrillary acidic protein as a brain injury biomarker in children undergoing extracorporeal membrane oxygenation. Pediatr Crit Care Med 2011; 12:572-9. [PMID: 21057367 PMCID: PMC3686089 DOI: 10.1097/pcc.0b013e3181fe3ec7] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine whether, in children, plasma glial fibrillary acidic protein is associated with brain injury during extracorporeal membrane oxygenation and with mortality. DESIGN Prospective, observational study. SETTING Pediatric intensive care unit in an urban tertiary care academic center. PATIENTS Neonatal and pediatric patients on extracorporeal membrane oxygenation (n = 22). INTERVENTIONS Serial blood sampling for glial fibrillary acidic protein measurements. MEASUREMENTS AND MAIN RESULTS Prospective patients age 1 day to 18 yrs who required extracorporeal membrane oxygenation from April 2008 to August 2009 were studied. Glial fibrillary acidic protein was measured using an electrochemiluminescent immunoassay developed at Johns Hopkins. Control samples were collected from 99 healthy children (0.5-16 yrs) and 59 neonatal intensive care unit infants without neurologic injury. In controls, the median glial fibrillary acidic protein concentration was 0.055 ng/mL (interquartile range, 0-0.092 ng/mL) and the 95th percentile of glial fibrillary acidic protein was 0.436 ng/mL. In patients on extracorporeal membrane oxygenation, plasma glial fibrillary acidic protein was measured at 6, 12, and every 24 hrs after cannulation. We enrolled 22 children who underwent extracorporeal membrane oxygenation. Median age was 7 days (interquartile range, 2 days to 9 yrs), and primary extracorporeal membrane oxygenation indication was: cardiac failure, six of 22 (27.3%); respiratory failure, 12 of 22 (54.5%); extracorporeal cardiopulmonary resuscitation, three of 22 (13.6%); and sepsis, one of 22 (4.6%). Seven of 22 (32%) patients developed acute neurologic injury (intracranial hemorrhage, brain death, or cerebral edema diagnosed by imaging). Fifteen of 22 (68%) survived to hospital discharge. In the extracorporeal membrane oxygenation group, peak glial fibrillary acidic protein levels were higher in children with brain injury than those without (median, 5.9 vs. 0.09 ng/mL, p = .04) and in nonsurvivors compared with survivors to discharge (median, 5.9 vs. 0.09 ng/mL, p = .04). The odds ratio for brain injury for glial fibrillary acidic protein >0.436 ng/mL vs. normal was 11.5 (95% confidence interval, 1.3-98.3) and the odds ratio for mortality was 13.6 (95% confidence interval, 1.7-108.5). CONCLUSIONS High glial fibrillary acidic protein during extracorporeal membrane oxygenation is significantly associated with acute brain injury and death. Brain injury biomarkers may aid in outcome prediction and neurologic monitoring of patients on extracorporeal membrane oxygenation to improve outcomes and benchmark new therapies.
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Extracorporeal membrane oxygenation for pediatric respiratory failure: Survival and predictors of mortality. Crit Care Med 2011; 39:364-70. [PMID: 20959787 DOI: 10.1097/ccm.0b013e3181fb7b35] [Citation(s) in RCA: 183] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE The last multicentered analysis of extracorporeal membrane oxygenation in pediatric acute respiratory failure was completed in 1993. We reviewed recent international data to evaluate survival and predictors of mortality. DESIGN Retrospective case series review. SETTING The Extracorporeal Life Support Organization Registry, which includes data voluntarily submitted from over 115 centers worldwide, was queried. The work was completed at the Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Medical Center, University of Utah, Salt Lake City, UT. SUBJECTS Patients aged 1 month to 18 yrs supported with extracorporeal membrane oxygenation for acute respiratory failure from 1993 to 2007. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS There were 3,213 children studied. Overall survival remained relatively unchanged over time at 57%. Considerable variability in survival was found based on pulmonary diagnosis, ranging from 83% for status asthmaticus to 39% for pertussis. Comorbidities significantly decreased survival to 33% for those with renal failure (n = 329), 16% with liver failure (n = 51), and 5% with hematopoietic stem cell transplantation (n = 22). The proportion of patients with comorbidities increased from 19% during 1993 to 47% in 2007. Clinical factors associated with mortality included precannulation ventilatory support longer than 2 wks and lower precannulation blood pH. CONCLUSIONS Although the survival of pediatric patients with acute respiratory failure treated with extracorporeal membrane oxygenation has not changed, this treatment is currently offered to increasingly medically complex patients. Mechanical ventilation in excess of 2 wks before the initiation of extracorporeal membrane oxygenation is associated with decreased survival.
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Vasavada R, Feng Qiu, Ündar A. Current status of pediatric/neonatal extracorporeal life support: clinical outcomes, circuit evolution, and translational research. Perfusion 2011; 26:294-301. [DOI: 10.1177/0267659111401673] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extracorporeal life support (ECLS) offers lifesaving mechanical circulatory support for patients afflicted with respiratory and/or cardiac failure. Neonatal respiratory patients have higher survival rates compared to pediatric patients, while, for cardiac cases, pediatric patients are more likely to survive. The indications for ECLS have been expanded due to the improved technology and favorable outcomes. However, the rate of mortality and morbidity for ECLS patients remains significant. Mechanical complications still comprise a large percentage of ECLS complications, leaving definite room for improvement in ECLS circuit technology in the future. As a pre-clinical evaluating tool, translational research will provide more useful information for the selection of ECLS devices, encourage further development of ECLS technology, and, ultimately, benefit the patients.
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Affiliation(s)
- Rahul Vasavada
- Penn State Hershey Pediatric Cardiovascular Research Center, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, USA
| | - Feng Qiu
- Penn State Hershey Pediatric Cardiovascular Research Center, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, USA
| | - Akif Ündar
- Penn State Hershey Pediatric Cardiovascular Research Center, Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, USA, Department of Surgery, Penn State Milton S. Hershey Medical Center, Penn State Hershey College of Medicine, Penn State Hershey Children's Hospital, Hershey, Pennsylvania, USA, Department of Bioengineering, Penn State Milton S. Hershey Medical Center, Penn State Hershey
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Custer JR. The evolution of patient selection criteria and indications for extracorporeal life support in pediatric cardiopulmonary failure: next time, let's not eat the bones. Organogenesis 2011; 7:13-22. [PMID: 21317556 DOI: 10.4161/org.7.1.14024] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Bill James, baseball statistician and author, tells the story of hungry cavemen sitting about a campfire, waiting for tomatoes to ripen. One has the inspiration to throw an ox on the fire, and the first barbecue ensued and was endured. After eating, the conversation goes something like this. "There were some good parts." "Yeah, but there were some bad parts." And the smart one says, "This time, let's not eat the bones." The evolution of patient selection criteria for the use of extracorporeal support (ECLS) is a bit like those cavemen and their first barbecued ox. Extracorporeal life support technology and application to patient care is the unique result of a long standing history of ambitious attempt, evaluation, debate, collaboration and extension.
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Affiliation(s)
- Joseph R Custer
- Division of Pediatric Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA.
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Abstract
OBJECTIVE To report a case of pH1N1 viral infection presenting as heart failure requiring mechanical extracorporeal life support. DESIGN Case report. SETTING Pediatric intensive care unit at a regional children's hospital. PATIENT Obese 15-yr-old boy who presented with pH1N1-related cardiomyopathy and respiratory failure that required extracorporeal membrane oxygenation. INTERVENTIONS Extracorporeal membrane oxygenation, echocardiography, high-frequency oscillating ventilation. MEASUREMENTS AND MAIN RESULTS Discovery of severe dilated cardiomyopathy and respiratory failure. CONCLUSIONS Patients with pH1N1 may present in profound heart failure in addition to respiratory failure. Extracorporeal membrane oxygenation may play an important role in managing these complex patients.
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Chronic granulomatous disease presenting as fulminant Aspergillus pneumonitis: a lethal combination? Pediatr Crit Care Med 2009; 10:e43-5. [PMID: 19584634 DOI: 10.1097/pcc.0b013e318198b22a] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE Case reports of two patients with unusually late initial presentation of chronic granulomatous disease with fulminant Aspergillus pneumonia. DATA SOURCES AND EXTRACTION Medical notes; retrospective study. STUDY SELECTION Identical pattern of clinical presentation in two patients referred for support with extracorporeal membrane oxygenation (ECMO). Our Institutional Review Board waived the need for consent. DATA SYNTHESIS Two school-aged boys presented with features of, and were initially treated, for community-acquired pneumonia. However, the disease course was rapidly progressive to fulminant respiratory failure and because both failed conventional intensive care management, they were referred to ECMO support. Although both died of evolving multiorgan failure, ECMO support allowed open lung biopsy leading to diagnosis of invasive Aspergillus pneumonia and chronic granulomatous disease. CONCLUSIONS Failure of adequate therapy for acute community-acquired pneumonia and rapid progression to respiratory failure should lead to the possibility of fungal etiology. Congenital immunodeficiency may present for the first time late in life, so acute invasive pulmonary aspergillosis in the absence of known risk factors should lead to consideration of chronic granulomatous disease regardless of patient age.
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Extracorporeal life support for severe respiratory failure in children with immune compromised conditions--what's in a name? Pediatr Crit Care Med 2009; 10:420; author reply 420-1. [PMID: 19433956 DOI: 10.1097/pcc.0b013e3181a0e37d] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Extracorporeal membrane oxygenation in immunocompromised patients: Avoiding the incurable or missing opportunities? Pediatr Crit Care Med 2008; 9:442-4. [PMID: 18496400 DOI: 10.1097/pcc.0b013e318172ec69] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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