Neurological injury after extracorporeal membrane oxygenation use to aid pediatric cardiopulmonary resuscitation

Managing medically refractory elevated intracranial pressure in a pediatric patient on ECMO: illustrative case

PURPOSE

We demonstrate the complexities of managing pediatric patients on extracorporeal membrane oxygenation (ECMO) therapy requiring neurosurgery, focusing on systemic anticoagulation, cardiac function, and medically refractory intracranial pressure (ICP).

METHODS

A 3.5-year-old female with Tetralogy of Fallot developed severe ischemic cerebral edema following post-operative cardiac arrest and required ECMO. This case, along with four additional cases of children requiring neurosurgery while on ECMO, was examined.

RESULTS

Emergency neurosurgical intervention in the primary case led to significant improvement, highlighting the delicate balance between managing ECMO-induced anticoagulation and urgent neurosurgical needs. The additional cases had variable outcomes, emphasizing the challenges of caring for these critically ill patients.

CONCLUSION

Successful management of children requiring ECMO support and neurosurgical intervention requires thoughtful multidisciplinary care. This report illustrates some of the nuances in such decision-making, and demonstrates one potential path to a good outcome.

Exploratory factor analysis yields grouping of brain injury biomarkers significantly associated with outcomes in neonatal and pediatric ECMO

In this two-center prospective cohort study of children on ECMO, we assessed a panel of plasma brain injury biomarkers using exploratory factor analysis (EFA) to evaluate their interplay and association with outcomes. Biomarker concentrations were measured daily for the first 3 days of ECMO support in 95 participants. Unfavorable composite outcome was defined as in-hospital mortality or discharge Pediatric Cerebral Performance Category > 2 with decline ≥ 1 point from baseline. EFA grouped 11 biomarkers into three factors. Factor 1 comprised markers of cellular brain injury (NSE, BDNF, GFAP, S100β, MCP1, VILIP-1, neurogranin); Factor 2 comprised markers related to vascular processes (vWF, PDGFRβ, NPTX1); and Factor 3 comprised the BDNF/MMP-9 cellular pathway. Multivariable logistic models demonstrated that higher Factor 1 and 2 scores were associated with higher odds of unfavorable outcome (adjusted OR 2.88 [1.61, 5.66] and 1.89 [1.12, 3.43], respectively). Conversely, higher Factor 3 scores were associated with lower odds of unfavorable outcome (adjusted OR 0.54 [0.31, 0.88]), which is biologically plausible given the role of BDNF in neuroplasticity. Application of EFA on plasma brain injury biomarkers in children on ECMO yielded grouping of biomarkers into three factors that were significantly associated with unfavorable outcome, suggesting future potential as prognostic instruments.

Long-Term Neurobehavioral and Functional Outcomes of Pediatric Extracorporeal Membrane Oxygenation Survivors

There are limited reports of neurobehavioral outcomes of children supported on extracorporeal membrane oxygenation (ECMO). This observational study aims to characterize the long-term (≥1 year) neurobehavioral outcomes, identify risk factors associated with neurobehavioral impairment, and evaluate the trajectory of functional status in pediatric ECMO survivors. Pediatric ECMO survivors ≥1-year postdecannulation and ≥3 years of age at follow-up were prospectively enrolled and completed assessments of adaptive behavior (Vineland Adaptive Behavior Scales, Third Edition [Vineland-3]) and functional status (Functional Status Scale [FSS]). Patient characteristics were retrospectively collected. Forty-one ECMO survivors cannulated at 0.0-19.8 years (median: 2.4 [IQR: 0.0, 13.1]) were enrolled at 1.3-12.8 years (median: 5.5 [IQR: 3.3, 6.5]) postdecannulation. ECMO survivors scored significantly lower than the normative population in the Vineland-3 Adaptive Behavior Composite (85 [IQR: 70, 99], P < 0.001) and all domains (Communication, Daily Living, Socialization, Motor). Independent risk factors for lower Vineland-3 composite scores included extracorporeal cardiopulmonary resuscitation, electrographic seizures during ECMO, congenital heart disease, and premorbid developmental delay. Of the 21 patients with impaired function at discharge (FSS ≥8), 86% reported an improved FSS at follow-up. Pediatric ECMO survivors have, on average, mild neurobehavioral impairment related to adaptive functioning years after decannulation. Continued functional recovery after hospital discharge is likely.

Neurologic Statistical Prognostication and Risk Assessment for Kids on Extracorporeal Membrane Oxygenation-Neuro SPARK

This study presents Neuro-SPARK, the first scoring system developed to assess the risk of neurologic injury in pediatric and neonatal patients on extracorporeal membrane oxygenation (ECMO). Using the extracorporeal life support organization (ELSO) registry, we applied robust machine learning methodologies and clinical expertise to a 10 years dataset. We produced separate models for veno-venous (V-V ECMO) and veno-arterial (V-A ECMO) configurations due to their different risk factors and prevalence of neurologic injury. Our models identified 14 predictor variables for V-V ECMO and 20 for V-A ECMO, which demonstrated moderate accuracy in predicting neurologic injury as defined by the area under the receiver operating characteristic (AUROC) (V-V = 0.63, V-A = 0.64) and good calibration as measured by the Brier score (V-V = 0.1, V-A = 0.15). Furthermore, our post-hoc analysis identified high- and low-risk groups that may aid clinicians in targeted neuromonitoring and guide future research on ECMO-associated neurologic injury. Despite the inherent limitations, Neuro-SPARK lays the foundation for a risk-assessment tool for neurologic injury in ECMO patients, with potential implications for improved patient outcomes.

Applications for ultrasound in pediatric surgery

Ultrasound (US) use within pediatric surgery is expanding rapidly. While US guidance for central line placement has been common practice for many years now, advances in the quality of images, portability of US machines, and a lack of radiation associated with imaging has led to broader application in many other aspects of surgery, ranging from diagnostics to performing operations under the direction of point-of-care ultrasound (POCUS). The relatively short learning curve for providers along with excellent image quality in children due to their small size provides an easy, effective imaging modality with diverse applications. Discussed here is a broad overview of the spectrum of US use within current pediatric surgical practices.

Long-term follow-up of neuropsychological complications in neonates undergoing extracorporeal membrane oxygenation: a systematic review and meta-analysis

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) has been widely used in severe neonatal diseases for approximately 50 years, while few studies have concentrated on the long-term follow-up of its neuropsychological development.

OBJECTIVE

To assess the long-term neuropsychological complications in children who underwent ECMO in infancy.

METHODS

The PubMed, Web of Science, Cochrane, and EMBASE databases were searched for retrieving studies published in the recent 10 years (until June 10, 2022). All studies were eligible that concentrated on the long-term follow-up of neuropsychological complications in neonates undergoing ECMO. Excluding animal studies, neonates with congenital craniocerebral dysplasia and studies with data from the same center performed at different times. Statistical analysis was performed using RevMan 5.3 and Stata/SE 12.0 software. A random-effects model was used to report results. The sensitivity analysis was utilized to identify sources of heterogeneity.

RESULTS

The meta-analysis of 10 studies that enrolled 1199 patients was conducted, showing the pooled morbidity of intelligence (pooled morbidity: 20.3%, 95% CI: 0.16-0.25, I2: 9.5%, P=0.33), motor activity (pooled morbidity: 10.3%, 95%CI: 0.07-0.14, I2: 43.5%, P=0.15), learning (pooled morbidity: 9.0%, 95%CI: -0.03-0.21, I2: 63.2%, P=0.10), hearing (pooled morbidity: 15.7%, 95%CI: 0.02-0.29, I2: 94.2%, P=0.00), vision (pooled morbidity: 18.5%, 95%CI: 0.12-0.25, I2: 0%, P=0.46), cognition (pooled morbidity: 26.3%, 95%CI: 0.19-0.34, I2: 0%, P=0.32), attention (pooled morbidity: 7.4%, 95%CI: 0.02-0.13, I2: 38.9%, P=0.20), speed in attention (pooled morbidity: 69.9%, 95%CI: 0.62-0.78), and accuracy in attention (pooled morbidity: 39.0%, 95%CI: 0.30-0.48) in neonates undergoing ECMO. The results of the Begg's test and sensitivity analysis indicated that the heterogeneity was originated from factors other than sample size.

CONCLUSION

This systematic review and meta-analysis showed that neonates undergoing ECMO were associated with various neuropsychological complications. Additional randomized controlled trials (RCTs) with a larger sample size and a higher quality are needed.

The 2023 AAN/AAP/CNS/SCCM Pediatric and Adult Brain Death/Death by Neurologic Criteria Consensus Practice Guideline: A Comparison With the 2010 and 2011 Guidelines

In collaboration with the American Academy of Pediatrics, Child Neurology Society, and Society for Critical Care Medicine, the American Academy of Neurology formulated an updated, evidence-informed consensus-based guideline for pediatric and adult brain death/death by neurologic criteria (BD/DNC) determination. In comparison with the prior guidelines, the revisions and additions in this guideline, which are summarized in this review, are intended to (1) ensure recommendations are conservative, yet practical, and emphasize circumstances in which BD/DNC determination should be delayed or deferred, so as to minimize the risk of a false-positive BD/DNC determination; and (2) provide guidance about aspects of BD/DNC determination that clinicians find challenging and/or controversial. We hope that clinicians throughout the United States will use this information to revise their hospital BD/DNC determination policies to conform to the standardized process for BD/DNC determination described in the new guideline, to ensure that every BD/DNC evaluation is consistent and accurate.

Machine learning-based predictor for neurologic outcomes in patients undergoing extracorporeal cardiopulmonary resuscitation

Background

We investigated the predictors of poor neurological outcomes in extracorporeal cardiopulmonary resuscitation (ECPR) patients using machine learning (ML) approaches.

Methods

This study was a retrospective, single-center, observational study that included adult patients who underwent ECPR while hospitalized between January 2010 and December 2020. The primary outcome was neurologic status at hospital discharge as assessed by the Cerebral Performance Categories (CPC) score (scores range from 1 to 5). We trained and tested eight ML algorithms for a binary classification task involving the neurological outcomes of survivors after ECPR.

Results

During the study period, 330 patients were finally enrolled in this analysis; 143 (43.3%) had favorable neurological outcomes (CPC score 1 and 2) but 187 (56.7%) did not. From the eight ML algorithms initially considered, we refined our analysis to focus on the three algorithms, eXtreme Gradient Boosting, random forest, and Stochastic Gradient Boosting, that exhibited the highest accuracy. eXtreme Gradient Boosting models exhibited the highest accuracy among all the machine learning algorithms (accuracy: 0.739, area under the curve: 0.837, Kappa: 0.450, sensitivity: 0.700, specificity: 0.740). Across all three ML models, mean blood pressure emerged as the most influential variable, followed by initial serum lactate, and arrest to extracorporeal membrane oxygenation (ECMO) pump-on-time as important predictors in machine learning models for poor neurological outcomes following successful ECPR.

Conclusions

In conclusion, machine learning methods showcased outstanding predictive accuracy for poor neurological outcomes in patients who underwent ECPR.

Blood-brain barrier dysfunction in intensive care unit

The central nervous system is characterized by a peculiar vascularization termed blood-brain barrier (BBB), which regulates the exchange of cells and molecules between the cerebral tissue and the whole body. BBB dysfunction is a life-threatening condition since its presence corresponds to a marker of severity in most diseases encountered in the intensive care unit (ICU). During critical illness, inflammatory response, cytokine release, and other phenomena activating the brain endothelium contribute to alterations in the BBB and increase its permeability to solutes, cells, nutrients, and xenobiotics. Moreover, patients in the ICU are often old, with underlying acute or chronic diseases, and overly medicated due to their critical condition; these factors could also contribute to the development of BBB dysfunction. An accurate diagnostic approach is critical for the identification of the mechanisms underlying BBB alterations, which should be rapidly managed by intensivists. Several methods were developed to investigate the BBB and assess its permeability. Nevertheless, in humans, exploration of the BBB requires the use of indirect methods. Imaging and biochemical methods can be used to study the abnormal passage of molecules through the BBB. In this review, we describe the structural and functional characteristics of the BBB, present tools and methods for probing this interface, and provide examples of the main diseases managed in the ICU that are related to BBB dysfunction.

Neonatal venoarterial and venovenous ECMO

ECMO remains an important support tool in the treatment of neonates with reversible congenital cardiopulmonary diseases. There are specific circumstances that call for either venoarterial (VA) or venovenous (VV) ECMO in neonates. While limited by the infant's the size and gestational age, ECMO can confer exceptional survival rates to a number of neonates who can often develop without devastating complications. However, it remains a labor and time intensive endeavor, which may be impractical or unattainable in resource-limited environments. While adult and pediatric ECMO indications and equipment options have expanded in recent years, neonatal ECMO continues to be a niche subspecialty requiring specific expertise and technical skill, especially considering the ever-changing neonatal physiology in the setting of cardiopulmonary support. It is critical to recognize the unique approaches to cannulation options, imaging, vessel management, anticoagulation, and monitoring protocols to achieve optimal outcomes. Thus, it becomes nearly impossible to separate the role of pediatric surgeons from the continuous involvement with and management of neonatal ECMO patients. This necessitates that pediatric surgeons in ECMO centers continue to hone their expertise and remain heavily involved in neonatal ECMO. This section reviews the most critical current approaches and unresolved controversies in neonatal ECMO with special attention to the practical aspects and decisions a surgeon faces in initiation and termination of neonatal ECMO.

Pediatric ECLS Neurologic Management and Outcomes

Neurologic complications associated with extracorporeal life support (ECLS), including seizures, ischemia/infarction, and intracranial hemorrhage significantly increase morbidity and mortality in pediatric and neonatal patients. Prompt recognition of adverse neurologic events may provide a window to intervene with neuroprotective measures. Many neuromonitoring modalities are available with varying benefits and limitations. Several pre-ECLS and ECLS-related factors have been associated with an increased risk for neurologic complications. These may be patient- or circuit-related and include modifiable and non-modifiable factors. ECLS survivors are at risk for long-term neurological sequelae affecting neurodevelopmental outcomes. Possible long-term outcomes range from normal development to severe impairment. Patients should undergo a neurological evaluation prior to discharge, and neurodevelopmental assessments should be included in each patient's structured, multidisciplinary follow-up. Safe pediatric and neonatal ECLS management requires a thorough understanding of neurological complications, neuromonitoring techniques and limitations, considerations to minimize risk, and an awareness of possible long-term ramifications. With a focus on ECLS for respiratory failure, this manuscript provides a review of these topics and summarizes best practice guidelines from international organizations and expert consensus.

Lessons Learned in Neurodevelopmental Outcomes Research in Children Following Extracorporeal Membrane Oxygenation

Neurodevelopmental outcomes research in children following extracorporeal membrane oxygenationis a complex and evolving field. From systematic reviews to multi-center prospective cohort studies, a variety of research endeavors in this domain have already been conducted. Recent attention has redirected the focus on biomarkers and imaging studies to help better understand the neurological, developmental, and behavioral effects of extracorporeal membrane oxygenation on surviving children. This review provides an overview of major research in the field, ongoing and future studies, and a summary of lessons learned from these efforts.

Extracorporeal cardiopulmonary resuscitation in adults and children: A review of literature, published guidelines and pediatric single-center program building experience

Extracorporeal cardiopulmonary resuscitation (ECPR) is an adjunct supportive therapy to conventional cardiopulmonary resuscitation (CCPR) employing veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in the setting of refractory cardiac arrest. Its use has seen a significant increase in the past decade, providing hope for good functional recovery to patients with cardiac arrest refractory to conventional resuscitation maneuvers. This review paper aims to summarize key findings from the ECPR literature available to date as well as the recommendations for ECPR set forth by leading national and international resuscitation societies. Additionally, we describe the successful pediatric ECPR program at Texas Children's Hospital, highlighting the logistical, technical and educational features of the program.

Incidence, risk factors, and outcomes in electroencephalographic seizures after mechanical circulatory support: A systematic review and meta-analysis

Purpose

To estimate the overall incidence, risk factors, and clinical outcomes of electroencephalographic (EEG) seizures for adults and children after mechanical circulatory support (MCS).

Method and measurements

This systematic review and meta-analysis were carried out in accordance with the PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analysis) guidance document. MEDLINE EMBASE and CENTRAL were investigated for relevant studies. The related information was retrieved by two independent reviewers and all analyses were conducted by STATA (version 16.0; Stata Corporation, College Station, TX, United States).

Result

Sixty studies including 36,191 adult and 55,475 pediatric patients with MCS were enrolled for evaluation. The study showed that the overall incidence of EEG seizures in adults was 2% (95%CI: 1–3%), in which 1% (95%CI: 1–2%) after cardiopulmonary bypass (CPB), and 3% (95%CI: 1–6%) after extracorporeal membrane oxygenation (ECMO). For pediatrics patients, the incidence of EEG seizures was 12% (95%CI: 11–14%), among which 12% (9–15%) after CPB and 13% (11–15%) after ECMO. The major risk factors of EEG seizures after MCS in adults were redo surgery (coefficient = 0.0436, p = 0.044), and COPD (coefficient = 0.0749, p = 0.069). In addition, the gestational week of CPB (coefficient = 0.0544, p = 0.080) and respiratory failure of ECMO (coefficient = –0.262, p = 0.019) were also indicated to be associated with EEG seizures in pediatrics.

Conclusion

EEG seizures after MCS were more common in pediatrics than in adults. In addition, the incidence of EEG seizure after ECMO was higher than CPB both in adults and children. It is expected that appropriate measures should be taken to control modifiable risk factors, thus improving the prognosis and increasing the long-term survival rate of MCS patients.

Systematic Review Registration

[https://www.crd.york.ac.uk/prospero], identifier [CRD42021287288].

Pediatric ECMO: unfavorable outcomes are associated with inflammation and endothelial activation

BACKGROUND

Inflammatory and endothelial activation responses during extracorporeal membrane oxygenation (ECMO) support in children are poorly understood. In this study, we aimed to determine if circulating inflammatory, endothelial activation, and fibrinolytic markers are associated with mortality and with neurologic outcomes in children on ECMO.

METHODS

We conducted a secondary analysis of a two-center prospective observational study of 99 neonatal and pediatric ECMO patients. Inflammatory (interferon gamma [IFNγ], interleukin-6 [IL-6], IL-1β, tumor necrosis factor alpha [TNFα]), endothelial activation (E-selectin, P-selectin, intercellular adhesion molecule-3 [ICAM-3], thrombomodulin [TM]), and fibrinolytic markers (tissue plasminogen activator [tPA], plasminogen activator inhibitor-1 [PAI-1]) were measured in plasma on days 1, 2, 3, 5, 7, and every third day thereafter during the ECMO course.

RESULTS

All ECMO day 1 inflammatory biomarkers were significantly elevated in children with abnormal vs. normal neuroimaging. ECMO day 1 and peak levels of IL-6 and PAI-1 were significantly elevated in children who died compared to those who survived to hospital discharge. Tested biomarkers showed no significant association with long-term neurobehavioral outcomes measured using the Vineland Adaptive Behavioral Scales, Second Edition.

CONCLUSIONS

High levels of circulating inflammatory, endothelial activation, and fibrinolytic markers are associated with mortality and abnormal neuroimaging in children on ECMO.

IMPACT

The inflammatory, endothelial activation, and fibrinolytic profile of children on ECMO differs by primary indication for extracorporeal support. Proinflammatory biomarkers on ECMO day 1 are associated with abnormal neurologic imaging in children on ECMO in univariable but not multivariable models. In multivariable models, a pronounced proinflammatory and prothrombotic biomarker profile on ECMO day 1 and longitudinally was significantly associated with mortality. Further studies are needed to identify inflammatory, endothelial, and fibrinolytic profiles associated with increased risk for neurologic injury and mortality through potential mediation of bleeding and thrombosis.

Compression Device-Assisted Extracorporeal Cardiopulmonary Resuscitation Cannulation in Pediatric Patients-A Simulation Study

Background: Surgical neck cannulation for pediatric extracorporeal cardiopulmonary resuscitation (ECPR) requires multiple interruptions of manual chest compressions to facilitate the procedure. Effective uninterrupted CPR is essential to prevent neurological injury. We hypothesized that an automated chest compression device can be used to provide effective and uninterrupted chest compressions during pediatric neck ECPR cannulation. The feasibility of surgically cannulating the right carotid artery and right internal jugular vein in an infant during ongoing automated chest compressions was tested in a simulation study. Methods: A working prototype of a pediatric chest compression device was designed to provide automated chest compressions on an infant CPR manikin at the rate of 120 compressions/minute. A feedback device attached to the manikin was used to monitor the effectiveness of CPR. A synthetic artery, vein along with carotid sheath and skin was utilized to simulate surgical neck exploration. ECPR simulation was conducted using the compression device to provide chest compressions. Results: Four ECPR simulations were conducted during which vessel sparing (n = 2) and non-vessel sparing (n = 2) cannulation of the right internal carotid artery and right internal jugular vein were performed during ongoing mechanical chest compressions. All four cannulations were successfully performed without the need to interrupt chest compressions. Conclusions: In a simulated environment, pediatric ECPR neck cannulation with uninterrupted chest compressions may be accomplished using an automated chest compression device. The strategy of compression device-assisted ECPR cannulation requires further study and could potentially reduce the neurological complications of ECPR.

Early Neurologic Complications and Long-term Neurologic Outcomes of Extracorporeal Membrane Oxygenation Performed in Children

BACKGROUND

We aimed at evaluating acute neurologic complications (ANC) and clinical outcome at a 2-year follow-up in children after extracorporeal membrane oxygenation (ECMO).

METHODS

We conducted a single-center, retrospective review of our patient cohort aged between 1 month and 18 years at the time of ECMO support (between June 2014 to January 2017). Outcome analysis included ANC and their clinical consequences.The Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) were used for neurologic assessment performed at discharge from the hospital and at 2nd year follow-up.

RESULTS

There were 35 children who required ECMO. The median ECMO time was 9 days (range 2-32 days). Decannulation from ECMO was achieved in 68.6% of patients, and overall, 42.8% survived (15 patients), The incidence of ANC in the surviving patients was 40% (6 children). ANC were intracranial hemorrhage, seizures, cerebral infarction, which occurred in one, two and three of the 15 surviving patients respectively (6.6, 13.3 and 20%). A higher rate of organ failure was related to death (p=0.043), whereas duration on ECMO was a risk factor for the development of ANC (p<0.05). At hospital discharge, the 14 patients evaluated had normal development or -mild disability in 73.2%, and at the 2-year follow-up, 93.4% had these scores.

CONCLUSION

Children who receive ECMO have a risk to develop ANC, which was related to the length of ECMO treatment, while survival was related to less organ failure, Long-term neurological outcome was good in our patient cohort.

Ethical Considerations in Ever-Expanding Utilization of ECLS: A Research Agenda

Technological advancements and rapid expansion in the clinical use of extracorporeal life support (ECLS) across all age ranges in the last decade, including during the COVID-19 pandemic, has led to important ethical considerations. As a costly and resource intensive therapy, ECLS is used emergently under high stakes circumstances where there is often prognostic uncertainty and risk for serious complications. To develop a research agenda to further characterize and address these ethical dilemmas, a working group of specialists in ECLS, critical care, cardiothoracic surgery, palliative care, and bioethics convened at a single pediatric academic institution over the course of 18 months. Using an iterative consensus process, research questions were selected based on: (1) frequency, (2) uniqueness to ECLS, (3) urgency, (4) feasibility to study, and (5) potential to improve patient care. Questions were categorized into broad domains of societal decision-making, bedside decision-making, patient and family communication, medical team dynamics, and research design and implementation. A deeper exploration of these ethical dilemmas through formalized research and deliberation may improve equitable access and quality of ECLS-related medical care.

Neurological Outcome According to the Site of Cannulation in Septic Children Supported by Venoarterial Extracorporeal Membrane Oxygenation

The impact of cervical cannulation on neurologic outcome has not been yet studied among children receiving venoarterial extracorporeal membrane oxygenation (VA-ECMO) in the context of severe sepsis or septic shock. A retrospective cohort study was performed using the extracorporeal life support organization (ELSO) registry. A total of 559 children weighing less than 20 kg with a primary or secondary diagnosis of severe sepsis, septic shock or toxic shock syndrome were included between January 1, 2010, and December 31, 2019. Cervical cannulation was performed in 485 children (87%) and central cannulation in 74 children (13%). The prevalence of acute neurologic event (ANE) was 32%, including clinical and/or electroencephalographic seizures, cerebral infarction, cerebral hemorrhage, and/or brain death. In multivariable analysis, we did not find an association between cervical cannulation and greater/lesser odds of ANE during ECMO (adjusted odds ratio [aOR] = 1.39, 95% confidence interval [CI] 0.72-2.65; P = 0.326). Only pre-ECMO acidosis was independently associated with the development of ANE (pH < 6.99; aOR = 2.71, 95% CI 1.34-5.49; P = 0.006; pH 6.99 to <7.12; aOR = 2.57, 95% CI 1.37-4.82; P = 0.003). Thus, the site of cannulation appears not as a modifiable neurologic risk factor in this young septic population.

A characterization of cortisol level and adrenal reservation in human cardiopulmonary arrest: systematic review and meta-analysis

BACKGROUND

Cardiopulmonary arrest (CPA) is an urgency, which is associated with high mortality. This systematic review evaluated the relationship between baseline cortisol level and the outcome of resuscitated CPA patients.

METHODS

We searched the following databases: PubMed, Scopus, ISI Web of Science, and Google Scholar. Relevant observational and controlled trials were explored from inception by April 2020. The quality of the articles was assessed using the Newcastle-Ottawa Scale (NOS).

RESULTS

Finally, five cohort studies (n = 201 participants in total) were eligible for including in the meta-analysis. The results of this meta-analysis showed that although the baseline serum cortisol levels were higher in survivors of cardiac arrest compared with non-survivors, the differences between groups do not reach a significance level (Hedges' g = 0.371, 95% CI, -0.727, 1.469, P value = 0.508). Between-study heterogeneity was statistically significant (Cochrane Q test: P value < 0.001, I2 = 89.323).

CONCLUSIONS

The result of the present meta-analysis was suggestive of a higher baseline serum cortisol levels in survivors of CPA. Future randomized controlled studies with a large sample size will determine the exact relationship between adrenal reservation and the eventual outcome of patients with CPA.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018085468.

Extracorporeal Life Support Organization (ELSO) Guidelines for Follow-up After Neonatal and Pediatric Extracorporeal Membrane Oxygenation

Neonates and children who have survived critical illness severe enough to require extracorporeal membrane oxygenation (ECMO) are at risk for neurologic insults, neurodevelopmental delays, worsening of underlying medical conditions, and development of new medical comorbidities. Structured neurodevelopmental follow-up is recommended for early identification and prompt interventions of any neurodevelopmental delays. Even children who initially survive this critical illness without new medical or neurologic deficits remain at risk of developing new morbidities/delays at least through adolescence, highlighting the importance of structured follow-up by personnel knowledgeable in the sequelae of critical illness and ECMO. Structured follow-up should be multifaceted, beginning predischarge and continuing as a coordinated effort after discharge through adolescence. Predischarge efforts should consist of medical and neurologic evaluations, family education, and co-ordination of long-term ECMO care. After discharge, programs should recommend a compilation of pediatric care, disease-specific care for underlying or acquired conditions, structured ECMO/neurodevelopmental care including school performance, parental education, and support. Institutionally, regionally, and internationally available resources will impact the design of individual center's follow-up program. Additionally, neurodevelopmental testing will need to be culturally and lingually appropriate for centers' populations. Thus, ECMO centers should adapt follow-up program to their specific populations and resources with the predischarge and postdischarge components described here.

Seizures in Children with Cardiac Disease on Extracorporeal Membrane Oxygenation

BACKGROUND

Children supported with extracorporeal membrane oxygenation (ECMO) have been shown to be at risk for developing seizures. However, previous studies have consisted of heterogeneous patient populations. We aimed to describe the rate of seizures in pediatric patients receiving ECMO for cardiac indications and to identify risk factors for the occurrence of this complication.

METHODS

This is a retrospective cohort study of consecutive pediatric patients on ECMO for congenital or acquired cardiac disease between 2014 and 2018 at a tertiary care pediatric hospital.

RESULTS

We reviewed 110 children, of whom 104 (95%) received continuous electroencephalogram for at least 48 h after ECMO initiation. Seizures were observed in 20 (18%) children. Seizures were subclinical only in 13 (65%) patients, and 8 (40%) developed status epilepticus. The median time from ECMO initiation to first seizure was 34 h (25%, 75%: 19, 44). Children with seizures were more likely to have suffered pre-ECMO cardiac arrest (odds ratio 5.7, 95% confidence interval 2.0-16.1, p < 0.001), require extracorporeal cardiopulmonary resuscitation (odds ratio 5.2, 95% confidence interval 1.9-14.7, p < 0.001), and have been cannulated via the cervical vessels (p = 0.029). Children with seizures also had lower pH nadir prior to ECMO (p = 0.015) and had higher peak lactate prior to ECMO (p = 0.002). Patients with seizures had significantly a longer median intensive care unit length of stay, (43 versus 32 days, p = 0.02), had a significantly worse pediatric cerebral performance score (2 versus 1, p = 0.03), and tended to have worse survival to hospital discharge (50% versus 71%, p = 0.069).

CONCLUSIONS

Seizures in pediatric patients on ECMO for cardiac indications are common, occurring in nearly one in five patients. Seizures are frequently subclinical only and often progress to status epilepticus. Continuous electroencephalogram is therefore warranted for this patient population, especially in the setting of cardiac arrest, extracorporeal cardiopulmonary resuscitation, or severe metabolic acidosis.

Cardiopulmonary Resuscitation and Rescue Therapies

The history of cardiopulmonary resuscitation and the Society of Critical Care Medicine have much in common, as many of the founders of the Society of Critical Care Medicine focused on understanding and improving outcomes from cardiac arrest. We review the history, the current, and future state of cardiopulmonary resuscitation.

Outcomes of Pediatric Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review and Meta-Analysis

OBJECTIVE

The goal of this work is to provide insight into survival and neurologic outcomes of pediatric patients supported with extracorporeal cardiopulmonary resuscitation.

DATA SOURCES

A systematic search of Embase, PubMed, Cochrane, Scopus, Google Scholar, and Web of Science was performed from January 1990 to May 2020.

STUDY SELECTION

A comprehensive list of nonregistry studies with pediatric patients managed with extracorporeal cardiopulmonary resuscitation was included.

DATA EXTRACTION

Study characteristics and outcome estimates were extracted from each article.

DATA SYNTHESIS

Estimates were pooled using random-effects meta-analysis. Differences were estimated using subgroup meta-analysis and meta-regression. The Meta-analyses Of Observational Studies in Epidemiology guideline was followed and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation system. Twenty-eight studies (1,348 patients) were included. There was a steady increase in extracorporeal cardiopulmonary resuscitation occurrence rate from the 1990s until 2020. There were 32, 338, and 1,094 patients' articles published between 1990 and 2000, 2001 and 2010, and 2010 and 2020, respectively. More than 70% were cannulated for a primary cardiac arrest. Pediatric extracorporeal cardiopulmonary resuscitation patients had a 46% (CI 95% = 43-48%; p < 0.01) overall survival rate. The rate of survival with favorable neurologic outcome was 30% (CI 95% = 27-33%; p < 0.01).

CONCLUSIONS

The use of extracorporeal cardiopulmonary resuscitation is rapidly expanding, particularly for children with underlying cardiac disease. An overall survival of 46% and favorable neurologic outcomes add credence to this emerging therapy.

Cerebral Emboli Monitoring Using Transcranial Doppler Ultrasonography in Adults and Children: A Review of the Current Technology and Clinical Applications in the Perioperative and Intensive Care Setting

Transcranial Doppler (TCD) ultrasonography is the only noninvasive bedside technology for the detection and monitoring of cerebral embolism. TCD may identify patients at risk of acute and chronic neurologic injury from gaseous or solid emboli. Importantly, a window of opportunity for intervention-to eliminate the source of the emboli and thereby prevent subsequent development of a clinical or subclinical stroke-may be identified using TCD. In this review, we discuss the application of TCD sonography in the perioperative and intensive care setting in adults and children known to be at increased risk of cerebral embolism. The major challenge for evaluation of emboli, especially in children, is the need to establish the ground truth and define true emboli identified by TCD. This requires the development and validation of a predictive TCD emboli monitoring technique so that appropriately designed clinical studies intended to identify specific modifiable factors and develop potential strategies to reduce pathologic cerebral embolic burden can be performed.

Risk factors and outcomes of pediatric extracorporeal membrane oxygenation

BACKGROUND

Congenital heart disease (CHD) is the most common neonatal and pediatric cardiac indication for extracorporeal membrane oxygenation (ECMO). Risk factors of survival and neurologic complication were different in many centers. We sought to evaluate survival and neurological outcome after ECMO in patients with CHD.

METHODS

We retrospectively reviewed the medical records of 37 patients (<16 years old) who received ECMO. Indications for ECMO were failure to wean from cardiopulmonary bypass in 18 patients, extracorporeal cardiopulmonary resuscitation (ECPR) in 13 patients, and others in 6 patients. The median cardiopulmonary resuscitation (CPR) duration in ECPR patients was 48 min (interquartile range: 38-53 min). Neurological outcomes were evaluated using the Pediatric Cerebral Performance Category (PCPC) scale one year after hospital discharge.

RESULTS

The median ECMO duration was 160 (91-286) h. Twenty-nine patients (78%) were successfully weaned off ECMO. Overall survival to hospital discharge was 59%. Risk factors of mortality were as follows: ECMO duration >1 week and urine output <1 mL/kg/h in the first 24 h after ECMO induction by multivariable analysis. Of the 22 survivors, 15 (68%) patients had a favorable outcome (PCPC ≤2). Risk factors for unfavorable outcomes (PCPC ≥3) included ECPR as indication and CPR of longer than 40 min.

CONCLUSIONS

Longer ECMO duration and lower urine output were associated with increased mortality. Neurologic outcomes were not satisfactory when CPR was required for a longer period before ECMO establishment.

Predictors of brain infarction in adult patients on extracorporeal membrane oxygenation: an observational cohort study

Non-hemorrhagic brain infarction (BI) is a recognized complication in adults treated with extracorporeal membrane oxygenation (ECMO) and associated with increased mortality. However, predictors of BI in these patients are poorly understood. The aim of this study was to identify predictors of BI in ECMO-treated adult patients. We conducted an observational cohort study of all adult patients treated with venovenous or venoarterial (VA) ECMO at our center between 2010 and 2018. The primary endpoint was a computed tomography (CT) verified BI. Logistic regression models were employed to identify BI predictors. In total, 275 patients were included, of whom 41 (15%) developed a BI. Pre-ECMO Simplified Acute Physiology Score III, pre-ECMO cardiac arrest, VA ECMO and conversion between ECMO modes were identified as predictors of BI. In the multivariable analysis, VA ECMO demonstrated independent risk association. VA ECMO also remained the independent BI predictor in a sub-group analysis excluding patients who did not undergo a head CT scan during ECMO treatment. The incidence of BI in adult ECMO patients may be higher than previously believed and is independently associated with VA ECMO mode. Larger prospective trials are warranted to validate these findings and ascertain their clinical significance.

Pediatric and neonatal extracorporeal life support: current state and continuing evolution

The use of extracorporeal life support (ECLS) for the pediatric and neonatal population continues to grow. At the same time, there have been dramatic improvements in the technology and safety of ECLS that have broadened the scope of its application. This article will review the evolving landscape of ECLS, including its expanding indications and shrinking contraindications. It will also describe traditional and hybrid cannulation strategies as well as changes in circuit components such as servo regulation, non-thrombogenic surfaces, and paracorporeal lung-assist devices. Finally, it will outline the modern approach to managing a patient on ECLS, including anticoagulation, sedation, rehabilitation, nutrition, and staffing.

Gross Motor Development of Children with Congenital Heart Disease Receiving Early Systematic Surveillance and Individualized Intervention: Brief Report

Purpose: This retrospective study aims to describe the gross motor development of children aged 4 to 24 months with congenital heart disease (CHD) enrolled in a systematic developmental follow-up program and to describe the frequency of physical therapy sessions they received between 4 and 8 months of age. Methods: Twenty-nine infants with CHD underwent motor evaluations using the AIMS at 4 months, and the Bayley-III at 12 and 24 months. Results: Based on AIMS, 79% of 4-month-old infants had a gross motor delay and required physical therapy. Among these, 56.5% received one to two physical therapy sessions, and 43.5% received three to six sessions. Infants who benefited from regular interventions tended to show a better improvement in motor scores from 12 to 24 months. Conclusion: This study highlights the importance of early motor screening in infants with CHD and suggests a potential benefit of early physical therapy in at-risk children. Abbreviations: CHD: Congenital heart disease; AIMS: Alberta Infant Motor Scales; Bayley-III: Bayley Scales of Infant and Toddler Development, Third edition; Bayley-III/GM: Gross Motor section of the Bayley Scales of Infant and Toddler Development, Third edition.

Mechanical circulatory support in paediatric population

Extra-corporeal membrane oxygenation is a life-saving modality to support the cardiac and/or pulmonary system as a form of life support in resuscitation, post-cardiotomy, as a bridge to cardiac transplantation and in respiratory failure. Its use in the paediatric and neonatal population has proven incredibly useful. However, extra-corporeal membrane oxygenation is also associated with a greater rate of mortality and complications, particularly in those with co-morbidities. As a result, interventions such as ventricular assist devices have been trialled in these patients. In this review, we provide a comprehensive analysis of the current literature on extra-corporeal membrane oxygenation for cardiac support in the paediatric and neonatal population. We evaluate its effectiveness in comparison to other forms of mechanical circulatory support and focus on areas for future development.

Pediatric Extracorporeal Cardiopulmonary Resuscitation: A Systematic Review

OBJECTIVES

This systematic review aims to summarize the body of available literature on pediatric extracorporeal cardiopulmonary resuscitation in order to delineate current utilization, practices, and outcomes, while highlighting gaps in current knowledge.

DATA SOURCES

PubMed, Embase, Scopus, Cochrane Library, and ClinicalTrials.gov databases.

STUDY SELECTION

We searched for peer-reviewed original research publications on pediatric extracorporeal cardiopulmonary resuscitation (patients < 18 yr old) and were inclusive of all publication years.

DATA EXTRACTION

Our systematic review used the structured Preferred Reporting Items for Systematic Reviews and Meta-Analyses methodology. Our initial literature search was performed on February 11, 2019, with an updated search performed on August 28, 2019. Three physician reviewers independently assessed the retrieved studies to determine inclusion in the systematic review synthesis. Using selected search terms, a total of 4,095 publications were retrieved, of which 96 were included in the final synthesis. Risk of bias in included studies was assessed using the Risk of Bias in Non-Randomized Studies of Interventions-I tool.

DATA SYNTHESIS

There were no randomized controlled trials of extracorporeal cardiopulmonary resuscitation use in pediatrics. A vast majority of pediatric extracorporeal cardiopulmonary resuscitation publications were single-center retrospective studies reporting outcomes after in-hospital cardiac arrest. Most pediatric extracorporeal cardiopulmonary resuscitation use in published literature is in cardiac patients. Survival to hospital discharge after extracorporeal cardiopulmonary resuscitation for pediatric in-hospital cardiac arrest ranged from 8% to 80% in included studies, and there was an association with improved outcomes in cardiac patients. Thirty-one studies reported neurologic outcomes after extracorporeal cardiopulmonary resuscitation, of which only six were prospective follow-up studies. We summarize the available literature on: determination of candidacy, timing of activation of extracorporeal cardiopulmonary resuscitation, staffing/logistics, cannulation strategies, outcomes, and the use of simulation for training.

CONCLUSIONS

This review highlights gaps in our understanding of best practices for pediatric extracorporeal cardiopulmonary resuscitation. We summarize current studies available and provide a framework for the development of future studies.

Clinical Determination of Brain Death in Children Supported by Extracorporeal Membrane Oxygenation

BACKGROUND/OBJECTIVE

Children supported by extracorporeal membrane oxygenation (ECMO) are at risk of catastrophic neurologic injury and brain death. Timely determination of brain death is important for minimizing psychological distress for families, resource allocation, and organ donation. Reports of successful determination of brain death in pediatric patients supported by ECMO are limited. The determination of brain death by clinical criteria requires apnea testing, which has historically been viewed as challenging in patients supported by ECMO. We report eight pediatric patients who underwent a total of 14 brain death examinations, including apnea testing, while supported by veno-arterial ECMO (VA-ECMO), resulting in six cases of clinical determination of brain death.

METHODS

We performed a retrospective review of the medical records of pediatric patients who underwent brain death examination while supported by VA-ECMO between 2010 and 2018 at a single tertiary care children's hospital.

RESULTS

Eight patients underwent brain death examination, including apnea testing, while supported by VA-ECMO. Six patients met criteria for brain death, while two had withdrawal of technical support after the first examination. During the majority of apnea tests (n = 13/14), the ECMO circuit was modified to achieve hypercarbia while maintaining oxygenation and hemodynamic stability. The sweep flow was decreased prior to apnea testing in ten brain death examinations, carbon dioxide was added to the circuit during three examinations, and ECMO pump flows were increased in response to hypotension during two examinations.

CONCLUSIONS

Clinical determination of brain death, including apnea testing, can be performed in pediatric patients supported by ECMO. The ECMO circuit can be effectively modified during apnea testing to achieve a timely rise in carbon dioxide while maintaining oxygenation and hemodynamic stability.

Early morbidities following paediatric cardiac surgery: a mixed-methods study

Background

Over 5000 paediatric cardiac surgeries are performed in the UK each year and early survival has improved to > 98%.

Objectives

We aimed to identify the surgical morbidities that present the greatest burden for patients and health services and to develop and pilot routine monitoring and feedback.

Design and setting

Our multidisciplinary mixed-methods study took place over 52 months across five UK paediatric cardiac surgery centres.

Participants

The participants were children aged < 17 years.

Methods

We reviewed existing literature, ran three focus groups and undertook a family online discussion forum moderated by the Children’s Heart Federation. A multidisciplinary group, with patient and carer involvement, then ranked and selected nine key morbidities informed by clinical views on definitions and feasibility of routine monitoring. We validated a new, nurse-administered early warning tool for assessing preoperative and postoperative child development, called the brief developmental assessment, by testing this among 1200 children. We measured morbidity incidence in 3090 consecutive surgical admissions over 21 months and explored risk factors for morbidity. We measured the impact of morbidities on quality of life, clinical burden and costs to the NHS and families over 6 months in 666 children, 340 (51%) of whom had at least one morbidity. We developed and piloted methods suitable for routine monitoring of morbidity by centres and co-developed new patient information about morbidities with parents and user groups.

Results

Families and clinicians prioritised overlapping but also different morbidities, leading to a final list of acute neurological event, unplanned reoperation, feeding problems, renal replacement therapy, major adverse events, extracorporeal life support, necrotising enterocolitis, surgical infection and prolonged pleural effusion. The brief developmental assessment was valid in children aged between 4 months and 5 years, but not in the youngest babies or 5- to 17-year-olds. A total of 2415 (78.2%) procedures had no measured morbidity. There was a higher risk of morbidity in neonates, complex congenital heart disease, increased preoperative severity of illness and with prolonged bypass. Patients with any morbidity had a 6-month survival of 81.5% compared with 99.1% with no morbidity. Patients with any morbidity scored 5.2 points lower on their total quality of life score at 6 weeks, but this difference had narrowed by 6 months. Morbidity led to fewer days at home by 6 months and higher costs. Extracorporeal life support patients had the lowest days at home (median: 43 days out of 183 days) and highest costs (£71,051 higher than no morbidity).

Limitations

Monitoring of morbidity is more complex than mortality, and hence this requires resources and clinician buy-in.

Conclusions

Evaluation of postoperative morbidity provides important information over and above 30-day survival and should become the focus of audit and quality improvement.

Future work

National audit of morbidities has been initiated. Further research is needed to understand the implications of feeding problems and renal failure and to evaluate the brief developmental assessment.

Funding

This project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 30. See the NIHR Journals Library website for further project information.

Survival and Mid-Term Neurologic Outcome After Extracorporeal Cardiopulmonary Resuscitation in Children

OBJECTIVES

Extracorporeal cardiopulmonary resuscitation in children with refractory cardiac arrest has been shown to improve survival, however, risk factors associated with mortality and neurologic impairments are not well defined. We analyzed our recent institutional experience with pediatric extracorporeal cardiopulmonary resuscitation to identify variables associated with survival and neurocognitive outcome.

DESIGN

Retrospective observational study.

SETTING

Pediatric cardiology and congenital heart surgery departments of a tertiary referral heart center.

PATIENTS

Seventy-two consecutive children (median age, 0.3 yr [0.0-1.9 yr]) who underwent extracorporeal cardiopulmonary resuscitation at our institution during the study period from 2005 to 2016.

INTERVENTIONS

Not applicable.

MEASUREMENTS AND MAIN RESULTS

Median duration of resuscitation was 60 minutes (42-80 min) and median extracorporeal support duration was 5.4 days (2.2-7.9 d). Forty-three (59.7%) extracorporeal cardiopulmonary resuscitation events occurred during off-hours, however, neither duration of resuscitation (65 min [49-89 min] vs 51 min [35-80 min]; p = 0.16) nor survival (34.9% vs 37.9%; p = 0.81) differed significantly compared to working hours. Congenital heart disease was present in 84.7% of the patients. Survival to hospital discharge was 36.1%; younger age, higher lactate levels after resuscitation, acute kidney injury, renal replacement therapy, hepatic injury, and complexity of prior cardiothoracic surgical procedures were significantly associated with mortality. At mid-term follow-up (median, 4.1 yr [3.7-6.1 yr]), 22 patients (84.6% of discharge survivors) were still alive with 77.3% having a favorable neurologic outcome. High lactate levels, arrest location other than ICU, and requirement for renal replacement therapy were associated with unfavorable neurologic outcome. Interestingly, longer duration of resuscitation did not negatively impact survival or neurologic outcome.

CONCLUSIONS

Extracorporeal cardiopulmonary resuscitation is a valuable tool for the treatment of children with refractory cardiac arrest and a favorable neurologic outcome can be achieved in the majority of survivors even after prolonged resuscitation. Mortality after extracorporeal cardiopulmonary resuscitation in postcardiac surgery children is associated with procedural complexity.

Controversies in Brain Death Declaration: Legal and Ethical Implications in the ICU

Purpose of review

This article provides a brief overview of the history and complexities of brain death determination. We examine a few legal cases that highlight some of the controversies surrounding the validity of brain death tests in light of varying state laws and institutional policy, the appropriateness of making religious accommodations, the dilemma of continuing organ-sustaining support in a pregnant brain-dead patient, and the issue of whether to obtain informed consent from surrogate decision makers before proceeding to testing.

Recent findings

In response to physician concerns about navigating these complex cases, especially with laws that vary from state to state, the American Academy of Neurology has published a position statement in January of 2019 endorsing brain death as the irreversible loss of all functions of the entire brain. It provides positions on the determination of brain death as well as guidance surrounding requests for accommodation.

Summary

Although death by neurologic criteria has been accepted as death medically for over 40 years, legal variance exists throughout the states, especially regarding religious accommodations and in pregnancy. Questions of whether to obtain informed consent from surrogate decision makers prior to brain death testing remain, and there is no guideline regarding obtaining ancillary testing. We expect to see continued cases that cause medical, legal, and ethical controversies in our ICUs. As such, uniform training in proper methodology in performing the brain death examination and appropriate use of ancillary testing is crucial, and there is a need for legal consistency in the acceptance of the medical standard.

Extracorporeal Cardiopulmonary Resuscitation (ECPR) in Infants and Children: A Single-Center Retrospective Study

BACKGROUND

Extracorporeal cardiopulmonary resuscitation (ECPR) is increasingly used to rescue patients with cardiac arrest refractory to conventional therapy, necessitating evaluation of factors that may affect outcomes.

METHODS

A single-center retrospective review of pediatric patients (<21 years old) who underwent ECPR from January 2010 to November 2017. Comparisons between nonsurvivors and survivors, to decannulation and discharge, were made. Factors associated with survival and rate of complications were examined.

RESULTS

Seventy patients were supported with ECPR. Forty-nine (70%) patients survived to decannulation and 38 (54%) patients to discharge. There was no statistical difference between baseline characteristics of survivors and nonsurvivors, including age at cannulation, weight (kg), time to cannulation (minutes), and total time on extracorporeal membrane oxygenation (hours). Survivors to discharge had significantly higher pH prior to cannulation compared to nonsurvivors (7.11 ± 0.24 vs 6.97 ± 0.21, P = .01). Of all, 23.2% of patients received renal replacement therapy (RRT), 39.4% had significant bleeding, 22.5% had thrombotic complications, and 68.8% had neurologic injury on imaging studies. A greater number of nonsurvivors received RRT compared to survivors to discharge (35.5% vs 10.8%, P = .02). There were no differences in bleeding or thrombotic complications or radiographically established neurologic injury.

CONCLUSIONS

Although ECPR effectively increases overall survival, a better characterization of long-term outcomes is needed.

Association of Cerebral Oximetry with Outcomes after Extracorporeal Membrane Oxygenation

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is associated with neurologic morbidity and mortality. We investigated whether cerebral regional oxygen saturation (rSO₂) is associated with neurologic outcomes and survival in children on ECMO.

METHODS

This was a retrospective observational study of children aged 1 day to 20 years who underwent ECMO with routine cerebral rSO₂ monitoring in the pediatric intensive care unit at a single academic center between February 2008 and September 2014. We collected all serial rSO₂ values recorded in the electronic medical record during the ECMO course. Favorable outcome was defined as survival with Pediatric Cerebral Performance Category (PCPC) ≤ 2 at hospital discharge or no decline from baseline PCPC.

RESULTS

We reviewed data from 153 patients who underwent 156 ECMO runs. The median age was 12.5 days (interquartile range [IQR], 2 days-15 months). Ninety-nine (64%) patients survived to hospital discharge, and 82/99 (83%) survivors had favorable neurologic outcome by discharge PCPC. Neuroimaging studies were obtained in 135 (87%) patients, 59 (44%) of which showed abnormal findings. Ninety-two (59%) patients had any rSO₂ ≤ 50%, 60 (38%) had any rSO₂ decline > 20% from baseline, and 26 (17%) had any rSO₂ decline > 20% from the reading 1 h prior. Any rSO₂ ≤ 50% and any rSO₂ decline > 20% from baseline were each associated with unfavorable outcome at hospital discharge (multivariable-adjusted odds ratio [OR], 2.82 [95% CI 1.10-7.25] and 4.52 [95% CI 1.76-11.58], respectively). rSO₂ decline > 20% from the reading 1 h prior was not significantly associated with the outcomes.

CONCLUSION

Among children in one institution who underwent routine clinical rSO₂ monitoring during ECMO, rSO₂ decline was associated with unfavorable short-term neurologic outcome and death after adjusting for potential confounders. The effectiveness of initiating early preventative measures in these high-risk patients needs further study.

A Pilot Study Identifying Brain-Targeting Adaptive Immunity in Pediatric Extracorporeal Membrane Oxygenation Patients With Acquired Brain Injury

Supplemental Digital Content is available in the text.

Objectives:

Extracorporeal membrane oxygenation provides short-term cardiopulmonary life support, but is associated with peripheral innate inflammation, disruptions in cerebral autoregulation, and acquired brain injury. We tested the hypothesis that extracorporeal membrane oxygenation also induces CNS-directed adaptive immune responses which may exacerbate extracorporeal membrane oxygenation-associated brain injury.

Design:

A single center prospective observational study.

Setting:

Pediatric and cardiac ICUs at a single tertiary care, academic center.

Patients:

Twenty pediatric extracorporeal membrane oxygenation patients (0–14 yr; 13 females, 7 males) and five nonextracorporeal membrane oxygenation Pediatric Logistic Organ Dysfunction score matched patients

Interventions:

None.

Measurements and Main Results:

Venous blood samples were collected from the extracorporeal membrane oxygenation circuit at day 1 (10–23 hr), day 3, and day 7 of extracorporeal membrane oxygenation. Flow cytometry quantified circulating innate and adaptive immune cells, and CNS-directed autoreactivity was detected using an in vitro recall response assay. Disruption of cerebral autoregulation was determined using continuous bedside near-infrared spectroscopy and acquired brain injury confirmed by MRI. Extracorporeal membrane oxygenation patients with acquired brain injury (n = 9) presented with a 10-fold increase in interleukin-8 over extracorporeal membrane oxygenation patients without brain injury (p < 0.01). Furthermore, brain injury within extracorporeal membrane oxygenation patients potentiated an inflammatory phenotype in adaptive immune cells and selective autoreactivity to brain peptides in circulating B cell and cytotoxic T cell populations. Correlation analysis revealed a significant relationship between adaptive immune responses of extracorporeal membrane oxygenation patients with acquired brain injury and loss of cerebral autoregulation.

Conclusions:

We show that pediatric extracorporeal membrane oxygenation patients with acquired brain injury exhibit an induction of pro-inflammatory cell signaling, a robust activation of adaptive immune cells, and CNS-targeting adaptive immune responses. As these patients experience developmental delays for years after extracorporeal membrane oxygenation, it is critical to identify and characterize adaptive immune cell mechanisms that target the developing CNS.

Neurologic Outcomes in a Two-Center Cohort of Neonatal and Pediatric Patients Supported on Extracorporeal Membrane Oxygenation

Contemporary studies of long-term outcomes in children supported on extracorporeal membrane oxygenation (ECMO) in the United States are limited. We enrolled 99 ECMO patients between July 2010 and June 2015 in a two-center prospective observational study that included neurologic and neuropsychologic evaluation at 6 and 12 months, using standardized outcome measures. Pre-ECMO, 20 (20%) had a pre-existing neurologic diagnosis, 40 (40%) had cardiac arrest, and 10 of 47 (21%) children with neuroimaging had acute abnormal findings. Of 50 children eligible for follow-up at 6 or 12 months, 40 (80%) returned for at least one visit. At the follow-up visit of longest interval from ECMO, the median Vineland Adaptive Behavior Scales-II (VABS-II) score was 91 (interquartile range [IQR], 81-98), the median Pediatric Stroke Outcome Measure (PSOM) score was 1 (IQR, 0-2), and the median Mullen Scales of Early Learning composite score was 85 (IQR, 72-96). Presence of new neuroimaging abnormalities during ECMO or within 6 weeks post-ECMO was associated with VABS-II score <85 or death within 12 months after ECMO. The Pediatric Cerebral Performance Category at hospital discharge showed a strong relationship with unfavorable VABS-II and PSOM scores at 6 or 12 months after ECMO. In this study, we report a higher prevalence of pre-ECMO neurologic conditions than previously described. In survivors to hospital discharge, median scores for adaptive behavior and cognitive, neurologic, and quality of life assessments were all below the general population means, but most deficits would be considered minor within each of the domains tested.

Contrast-Enhanced Ultrasound in Extracorporeal Support: In Vitro Studies and Initial Experience and Safety Data in the Extreme Premature Fetal Lamb Maintained by the Extrauterine Environment for Neonatal Development

OBJECTIVES

To evaluate the effects of ultrasound contrast agent (UCA) administration on hemodynamic parameters and support equipment in in vitro and in vivo models of extracorporeal support.

METHODS

In vitro, incrementally increasing bolus doses of a UCA were administered proximal to a membrane oxygenator, and ultrasound cine clips were obtained. The rates of microbubble destruction across the oxygenator and over time were calculated from time-intensity-curves. Measurements across the membrane oxygenator were recorded and compared by a repeated-measures analysis of variance. In vivo, 7 premature fetal lambs were transferred from placental support to the extrauterine environment for neonatal development. Contrast agent boluses were administered for contrast-enhanced ultrasound (CEUS) examinations. Hemodynamic parameters and serum laboratory values were evaluated before and after the examinations by paired t tests. For oxygenator staining, oxygenator membranes from the in vitro circuit, study animals (n = 4), and control animals (n = 4) were stained for the adherent UCA.

RESULTS

In vitro, with all doses (0.1-4 mL), there was no difference in measured parameters across the oxygenator (P ≥ .09). Contrast agent destruction (3%-14%) across the oxygenator was observed at the first pass with a progressive decline in contrast intensity over time. In vivo, there was no difference in hemodynamic parameters or serum laboratory values (P ≥ .08) with any CEUS examination (n = 17). For oxygenator staining, all oxygenator membranes were negative for UCA with lipid staining.

CONCLUSIONS

The UCA had no detectable effect on the oxygenator or measured parameters in in vitro and in vivo studies, thus providing additional safety data to support the use of CEUS in the setting of extracorporeal support.

A Case Report of A Drop Foot Developed After Common Femoral Artery Cannulation for Venoarterial Extracorporeal Membrane Oxygenation

The drop foot cases that are associated with developing neuropathies as a result of acute compartment syndrome or femoral artery ischemia after having cannulation for venoarterial extracorporeal membrane oxygenation (VA-ECMO) have been reported rarely in literature. In this case report, female patients who are 21 years old and developed drop foot depending on ECMO during the process of lung transplantation will be presented as both to be one of the rare neurological complications connected to ECMO and its possible causes will be analyzed.

The quality of life in extracorporeal life support survivors: single-center experience of a long-term follow-up

OBJECTIVE

To evaluate the health-related quality of life on a very long-term follow-up in patients treated with extracorporeal membrane oxygenation (ECMO) during neonatal and pediatric age.

DESIGN

Prospective follow-up study.

SETTING

Pediatric Intensive Care Unit of a tertiary-care University-Hospital.

PATIENTS

Out of 20 neonates and 21 children treated with ECMO in our center, 24 patients underwent short-term neurological follow-up. Twenty of them underwent long-term neurological follow-up.

INTERVENTION

Short-term follow-up was performed at 18 months and consisted in clinical evaluation, electroencephalography, and neuroimaging. Long-term follow-up was performed in 2017, at the mean period 19.72 years from ECMO (median 20.75, range 11.50-24.08) and consisted in a standardized questionnaires self-evaluation (PedsQL 4.0 Generic Core Scale) of health-related quality of life and an interviewed about the presence of organ morbidity, school level, or work position.

MEASUREMENTS AND MAIN RESULTS

Sixty-one percent (25/41) of the patients survived within 30 days after ECMO treatment. Short-term follow-up was performed in 24 patients (1 patient but died before the evaluation): 21 patients (87%) showed a normal neurological status, and 3 developed severe disability. Long-term follow-up was performed in 20 long-term survivors (3 patients were not possible to be contacted and considered lost to follow-up): mean age of patients at long-term follow-up was 21.23 (median 20.96, range 13.33-35.58) years; 90% (18/20) of them have no disability with a complete normal quality of life and 95% have no cognitive impairment.

CONCLUSIONS

ECMO represents a life-saving treatment for infants and children with respiratory and/or heart failure; survivors show a good quality of life comparable to healthy peers.

Influence of cannula positioning on brain injury during extracorporeal membrane oxygenation

Background

In veno-arterial extracorporeal membrane oxygenation (V-A ECMO), a patient is cannulated using either an atrio-aortic technique (central type ECMO; cECMO) or a femoro-femoral technique (peripheral type ECMO; pECMO). The direction of the pump flow at the aortic arch is anterograde from the ascending aorta in cECMO and retrograde from the descending aorta in pECMO. Hemodynamic differences from the position of the cannulas may influence the brain differently. To evaluate the effect of ECMO cannula positioning on the brain, hemodynamic data and plasma biomarkers were collected.

Methods

Eight pigs were randomly divided into the cECMO group (n=4) or pECMO group (n=4). ECMO was administered for 6 hours at a pump flow rate based on the mean flow of the ascending aorta. Mean arterial pressure (MAP), mean arterial flow (MAF), energy equivalent pressure (EEP), and surplus hemodynamic energy (SHE) were measured in the brachiocephalic artery every 30 minutes. During ECMO treatment, plasma was collected for analysis of interleukin-6 (IL-6), S100B, glial fibrillary acidic protein (GFAP), and neuron-specific enolase. The data were analyzed using the Mann-Whitney U tests, and repeated measures ANOVAs; significance was set at P<0.05.

Results

MAP and EEP at 1 and at 3 hours, MAF at all measured times, and SHE at 1 hour and 6 hours were significantly higher in the pECMO group. There was no significant difference in the levels of brain injury biomarkers between cECMO and pECMO groups.

Conclusions

The hemodynamic data showed that pECMO was superior to cECMO. Based on the biomarker data, neither pECMO nor cECMO for 6 hours caused evidence of brain injury.

Prevalence of Seizures in Pediatric Extracorporeal Membrane Oxygenation Patients as Measured by Continuous Electroencephalography

OBJECTIVES

Standards for neuromonitoring during extracorporeal membrane oxygenation support do not currently exist, and there is wide variability in practice. We present our institutional experience at an academic children's hospital since establishment of a continuous electroencephalography monitoring protocol for extracorporeal membrane oxygenation patients.

DESIGN

Retrospective, single-center study.

SETTING

Neonatal ICU and PICU in an urban, quaternary care center.

PATIENTS

All neonatal and pediatric patients requiring extracorporeal membrane oxygenation.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

During the study period, 70 patients were cannulated for extracorporeal membrane oxygenation and had continuous electroencephalography monitoring for greater than 24 hours. Electroencephalographic seizures were observed in 16 of 70 patients (23%), including five patients (7%) who were in status epilepticus. Among patients with continuous electroencephalography seizures, nine (56%) had subclinical nonconvulsive status epilepticus and eight (50%) had seizures in the initial 24 hours of extracorporeal membrane oxygenation support. Survival to hospital discharge was significantly greater for extracorporeal membrane oxygenation patients without seizures (74% vs 44%; p = 0.02).

CONCLUSIONS

Seizures occur in a significant proportion of pediatric and neonatal extracorporeal membrane oxygenation patients, frequently in the initial 24 hours after extracorporeal membrane oxygenation cannulation. Because seizures are associated with significantly decreased survival, neuromonitoring early in the extracorporeal membrane oxygenation course is important and useful. Further studies are needed to correlate electroencephalography findings with neurologic outcome.

Extracorporeal Cardiopulmonary Resuscitation in Children of Asia Pacific: A Retrospective Analysis of Extracorporeal Life Support Organization Registry

Background

Recent advances in extracorporeal membrane oxygenation (ECMO) have led to increasing interest in its use during cardiopulmonary resuscitation (CPR). However, decisions regarding extracorporeal CPR (ECPR) in children are difficult as a result of limited studies, especially in Asia Pacific. The objective of this study was to investigate trends in survival and demographic details for children with ECPR in Asia Pacific recorded in the Extracorporeal Life Support Organization (ELSO) registry from 1999 to 2016 and identify the risk factors associated with in-hospital mortality.

Methods

The data of children younger than 18 years of age who received ECPR over the past 18 years in Asia Pacific were retrospectively analyzed. The data were extracted from the ELSO registry and divided into two 9-year groups (Group 1: 1999-2007 and Group 2: 2008-2016) to assess temporal changes using univariate analysis. Then, univariate and multiple logistic regression analyses were performed between survivors and nonsurvivors to identify factors independently associated with in-hospital mortality.

Results

A total of 321 children were included in final analysis, with an overall survival rate of 50.8%. Although survival rates were similar between Group 1 and Group 2 (43.1% vs. 52.5%, χ² = 1.67, P = 0.196), the median age (1.7 [0.3, 19.2] months for Group 1 vs. 5.6 [0.8, 64.9] months for Group 2, t = -2.93, P = 0.003) and weight (3.7 [3.0, 11.5] kg for Group 1 vs. 6.0 [3.4, 20.3] kg for Group 2, t = -3.14, P = 0.002) of children increased over time, while the proportion of congenital heart disease (75.9% for Group 1 vs. 57.8% for Group 2, χ² = 6.52, P = 0.011) and cardiogenic shock (36.2% for Group 1 vs. 7.2% for Group 2, χ² = 36.59, P < 0.001) decreased. Patient conditions before ECMO were worse, while ECMO complications decreased across time periods, especially renal complications. Multiple logistic regression analysis of ECMO complications showed that disseminated intravascular coagulation (DIC), myocardial stunning, and neurological complications were independently associated with increased odds of hospital mortality.

Conclusions

The broader indications and decreased complication rates make EPCR to be applicated more and more extensive in children in Asia Pacific region. ECMO complications such as myocardial stunning are independently associated with decreased survival.