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Patterson KN, Beyene TJ, Gil LA, Fabia R, Minneci PC, Thakkar RK. Extracorporeal Membrane Oxygenation in Pediatric Burn Patients Without Inhalation Injury: A Unique Population? J Burn Care Res 2023; 44:419-424. [PMID: 35788846 DOI: 10.1093/jbcr/irac093] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Indexed: 11/12/2022]
Abstract
Prolonged mechanical ventilation (MV) before the initiation of extracorporeal membrane oxygenation (ECMO) is associated with decreased survival. Pediatric burn patients without inhalational injury are a unique population as they may be intubated for longer durations due to frequent interventions such as dressing changes and burn excisions. This study utilized the Extracorporeal Life Support Organization registry and evaluated patients 0 to 18 years old placed on ECMO and with a burn injury from January 2010 to December 2020. Inhalation injury was excluded. Descriptive statistics and bivariate analyses were performed. Multivariable logistic regression was used to assess the association between mortality and precannulation MV duration before ECMO cannulation, and odds ratios and predicted probabilities of mortality were estimated. Our cohort of 47 patients had a median age of 2.7 years old. Mortality occurred in 48.9% of the cohort. The overall median number of days on ECMO was 6.3 days, with no difference between survivors and non-survivors (6.8 days vs 6.3 days; P = .67). Survivors were ventilated for 4.1 days and non-survivors for 4.8 days before cannulation (P = .25). Regression modeling demonstrated that with each additional day on MV before ECMO cannulation, the odds of mortality increases by 12% (P = .03). Our study suggests that, similar to pediatric patients without thermal injury, increasing precannulation MV duration is associated with an increasing risk of mortality in pediatric burn patients without inhalational injury. Though the pediatric burn population is unique, evaluation of burn patients with respiratory failure for ECMO should be similar to the general population.
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Affiliation(s)
- Kelli N Patterson
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Tariku J Beyene
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Lindsay A Gil
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Renata Fabia
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Center for Pediatric Trauma Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Peter C Minneci
- Center for Surgical Outcomes Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA.,Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Rajan K Thakkar
- Division of Pediatric Surgery, Nationwide Children's Hospital, Columbus, Ohio, USA.,Center for Pediatric Trauma Research, Abigail Wexner Research Institute at Nationwide Children's Hospital, Columbus, Ohio, USA
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Coletti K, Griffiths M, Nies M, Brandal S, Everett AD, Bembea MM. Cardiac Dysfunction Biomarkers Are Associated With Potential for Successful Separation From Extracorporeal Membrane Oxygenation in Children. ASAIO J 2023; 69:198-204. [PMID: 35544447 PMCID: PMC9637889 DOI: 10.1097/mat.0000000000001759] [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: 02/04/2023] Open
Abstract
Biomarkers of cardiac dysfunction may aid in decision making about organ recovery and optimal timing of separation from extracorporeal membrane oxygenation (ECMO). We conducted a prospective observational study of children from 0 to <18 years who underwent ECMO between 7/2010 and 6/2015 in a single center. In this pilot study, we aimed to determine whether Suppression of tumorigenicity 2 (ST2), N -terminal pro-B-type natriuretic peptide (NT-proBNP), galectin-3, and endostatin were associated with ability to separate from ECMO. Fifty neonatal and pediatric participants supported on venoarterial ECMO were included (median age 13 days, 50% male). Twelve (24%) participants were unable to separate from extracorporeal support. Plasma ST2 concentrations at cannulation were higher in children who were ultimately unable to separate versus those who successfully separated from ECMO (median 395.3 ng/mL vs. 207.4 ng/mL, p = 0.012). ST2 and NT-proBNP concentrations decreased significantly from the first to the last ECMO day in patients successfully separated from ECMO ( p < 0.0001 and p = 0.017, respectively). Endostatin concentrations increased significantly from the first to the last ECMO day in both groups. Galectin-3 concentrations were not associated with the ability to separate from ECMO. Cardiac dysfunction biomarkers, particularly ST2, may aid in decannulation decision-making in pediatric ECMO patients. These results should be validated with a larger study.
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Affiliation(s)
- Kristen Coletti
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Megan Griffiths
- Department of Pediatrics, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melanie Nies
- Department of Pediatrics, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Stephanie Brandal
- Department of Pediatrics, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Allen D Everett
- Department of Pediatrics, Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Melania M Bembea
- From the Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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3
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TAFELSKI S, LANGE M, WEGENER F, GRATOPP A, SPIES C, WERNECKE KD, NACHTIGALL I. Pneumonia in pediatric critical care medicine and the adherence to guidelines. Minerva Pediatr (Torino) 2022; 74:447-454. [DOI: 10.23736/s2724-5276.19.05508-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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4
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Yehya N, Khemani RG, Erickson S, Smith LS, Rowan CM, Jouvet P, Willson DF, Cheifetz IM, Ward S, Thomas NJ. Respiratory Dysfunction Criteria in Critically Ill Children: The PODIUM Consensus Conference. Pediatrics 2022; 149:S48-S52. [PMID: 34970679 DOI: 10.1542/peds.2021-052888g] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Respiratory dysfunction is a component of every organ failure scoring system developed, reflecting the significance of the lung in multiple organ dysfunction syndrome. However, existing systems do not reflect current practice and are not consistently evidence based. OBJECTIVE We aimed to review the literature to identify the components of respiratory failure associated with outcomes in children, with the purpose of developing an operational and evidence-based definition of respiratory dysfunction. DATA SOURCES Electronic searches of PubMed and Embase were conducted from 1992 to January 2020 by using a combination of medical subject heading terms and text words to define respiratory dysfunction, critical illness, and outcomes. STUDY SELECTION We included studies of critically ill children with respiratory dysfunction that evaluated the performance of metrics of respiratory dysfunction and their association with patient-centered outcomes. Studies in adults, studies in premature infants (≤36 weeks' gestational age), animal studies, reviews and commentaries, case series with sample sizes ≤10, and studies not published in English in which we were unable to determine eligibility criteria were excluded. DATA EXTRACTION Data were abstracted into a standard data extraction form. RESULTS We provided binary (no or yes) and graded (no, nonsevere, or severe) definitions of respiratory dysfunction, prioritizing oxygenation and respiratory support. The proposed criteria were approved by 82% of members in the first round, with a score of 8 of 9 (interquartile range 7-8). LIMITATIONS Exclusion of non-English publications, heterogeneity across the pediatric age range, small sample sizes, and incomplete handling of confounders are limitations. CONCLUSIONS We propose definitions for respiratory dysfunction in critically ill children after an exhaustive literature review.
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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
| | - Robinder G Khemani
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital Los Angeles and Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Simon Erickson
- Department of Paediatric Critical Care, Perth Children's Hospital and The University of Western Australia, Perth, Western Australia, Australia
| | - Lincoln S Smith
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, University of Washington and Seattle Children's Hospital, Seattle, Washington
| | - Courtney M Rowan
- Division of Pediatric Critical Care, Department of Pediatrics, School of Medicine, Indiana University and Riley Hospital for Children, Indianapolis, Indiana
| | - Philippe Jouvet
- Department of Paediatrics; Sainte-Justine Hospital and University of Montreal, Montreal, Quebec, Canada
| | - Doug F Willson
- Department of Pediatrics, Virginia Commonwealth University, Richmond, Virginia
| | - Ira M Cheifetz
- Department of Pediatrics, Rainbow Babies and Children's Hospital and School of Medicine, Case Western Reserve University, Cleveland, Ohio
| | - Shan Ward
- Division of Critical Care, Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital San Francisco, San Francisco, California.,Division of Critical Care, Department of Pediatrics, University of California, San Francisco Benioff Children's Hospital Oakland, Oakland, California
| | - Neal J Thomas
- Division of Pediatric Critical Care Medicine, Departments of Pediatrics and Public Health Science, The Pennsylvania State University and Hershey Children's Hospital, Hershey, Pennsylvania
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Martucci G, di Francesco F, Panarello G, Piazza M, de Ville de Goyet J, Arcadipane A. Inferior vena cava surgical cannulation for infants needing veno-venous extracorporeal membrane oxygenation. Perfusion 2021; 37:128-133. [PMID: 33412989 DOI: 10.1177/0267659120987089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Femoral cannulation for veno-venous extracorporeal membrane oxygenation is challenging in infants because of the diameter of the vein. CASE REPORT Prolonged ECMO support (67 days) was necessary for an 8-month-old (8 kg) girl with acute respiratory distress syndrome that was caused by H1N1 influenza. After 30 days on ECMO support and using a single 16 Fr double-lumen cannula (internal jugular vein), a second cannula was necessary to ensure adequate flow. This second 12 Fr single-lumen cannula was surgically placed through the right common iliac vein. An excellent flow profile was then achieved and ECMO continued successfully for 37 more days. DISCUSSION As a lifesaving option, this double caval configuration successfully optimized the flow profile and oxygenation, outweighing the related risks. CONCLUSION In small children, a surgical approach to the inferior vena cava can be considered safe, especially in those cases where there is a shortage of adequate cannulas, or when central venous access is difficult.
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Affiliation(s)
- Gennaro Martucci
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | - Fabrizio di Francesco
- Pediatric Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Giovanna Panarello
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | - Marcello Piazza
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
| | - Jean de Ville de Goyet
- Pediatric Department for the Treatment and Study of Abdominal Diseases and Abdominal Transplantation, IRCCS-ISMETT, Palermo, Italy
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, IRCCS-ISMETT, Palermo, Italy
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6
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Bailly DK, Furlong-Dillard JM, Winder M, Lavering M, Barbaro RP, Meert KL, Bratton SL, Dalton H, Reeder RW. External validation of the Pediatric Extracorporeal Membrane Oxygenation Prediction model for risk adjusting mortality. Perfusion 2020; 36:407-414. [PMID: 32862782 PMCID: PMC7956121 DOI: 10.1177/0267659120952979] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
INTRODUCTION The Pediatric Extracorporeal Membrane Oxygenation Prediction (PEP) model was created to provide risk stratification for all pediatric patients requiring extracorporeal life support (ECLS). Our purpose was to externally validate the model using contemporaneous cases submitted to the Extracorporeal Life Support Organization (ELSO) registry. METHODS This multicenter, retrospective analysis included pediatric patients (<19 years) during their initial ECLS run for all indications between January 2012 and September 2014. Median values from the BATE dataset for activated partial thromboplastin time and internationalized normalized ratio were used as surrogates as these were missing in the ELSO group. Model discrimination was evaluated using area under the receiver operating characteristic curve (AUC), and goodness-of-fit was evaluated using the Hosmer-Lemeshow test. RESULTS A total of 4,342 patients in the ELSO registry were compared to 514 subjects from the bleeding and thrombosis on extracorporeal membrane oxygenation (BATE) dataset used to develop the PEP model. Overall mortality was similar (42% ELSO vs. 45% BATE). The c-statistic after external validation decreased from 0.75 to 0.64 and model calibration decreases most in the highest risk deciles. CONCLUSION Discrimination of the PEP model remains modest after external validation using the largest pediatric ECLS cohort. While the model overestimates mortality for the highest risk patients, it remains the only prediction model applicable to both neonates and pediatric patients who require ECLS for any indication and thus maintains potential for application in research and quality benchmarking.
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Affiliation(s)
- David K Bailly
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Jamie M Furlong-Dillard
- Department of Pediatric Critical Care, Norton Children's Hospital/University of Louisville, Louisville, KY, USA
| | - Melissa Winder
- Department of Pediatric Critical Care, Primary Children's Hospital, Salt Lake City, UT, USA
| | | | - Ryan P Barbaro
- Department of Pediatrics and Communicable Diseases, University of Michigan, Ann Arbor, MI, USA
| | - Kathleen L Meert
- Department of Pediatrics, Children's Hospital of Michigan, Detroit, MI, USA
| | - Susan L Bratton
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
| | - Heidi Dalton
- Department of Pediatrics, Inova Fairfax Hospital, Fall Church, VA, USA
| | - Ron W Reeder
- Division of Pediatric Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, UT, USA
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Ning B, Liang L, Lyu Y, Yu Y, Li B. The effect of high-frequency oscillatory ventilation or airway pressure release ventilation on children with acute respiratory distress syndrome as a rescue therapy. Transl Pediatr 2020; 9:213-220. [PMID: 32775239 PMCID: PMC7347764 DOI: 10.21037/tp-19-178] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
BACKGROUND To investigate the effects of high-frequency oscillatory ventilation (HFOV) or airway pressure release ventilation (APRV) as a rescue therapy on children with moderate and severe acute respiratory distress syndrome (ARDS). METHODS We retrospectively enrolled 47 children with ARDS who were transitioned from synchronized intermittent mandatory ventilation (SIMV) to either HFOV or APRV for 48 h or longer after failure of SIMV. The parameters of demographic data, arterial blood gases, ventilator settings, oxygenation index (OI), and PaO2/FiO2 (PF) ratio during the first 48 h of HFOV and APRV were recorded. RESULTS There was no significant difference between the HFOV and APRV groups with survival rates of 60% and 72.7%, respectively. Compared to pre-transition, the mean airway pressures at 2 and 48 h after transition were higher in both groups (P<0.01), and the PF ratio at 2 and 48 h in both modes was significantly improved (P<0.001). PF ratio and PaCO2 have significant differences at 48 h between two groups. The OI at 2 h after transition had no improvement in either group and was substantially lower at 48 h relative to the pre-transition level (P<0.001) in both groups. At 48 h after the transition to both HFOV and APRV, the survivors had lower mean airway pressures, higher PF ratios, and a lower OIs than non-survivors (P<0.01). CONCLUSIONS There was no significant difference on the survival rates of HFOV and APRV application as a rescue therapy for ARDS, but improved oxygenation at 48 h reliably discriminated survivors from non-survivors in both groups.
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Affiliation(s)
- Botao Ning
- Pediatric Intensive Care Unit, Shanghai Children's Medical Center affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Lingfang Liang
- Pediatric Intensive Care Unit of Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yi Lyu
- Department of Anesthesia, Minhang Hospital, Fudan University, Shanghai, China
| | - Ying Yu
- Department of Anesthesia, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Biru Li
- Pediatric Intensive Care Unit, Shanghai Children's Medical Center affiliated with Shanghai Jiao Tong University School of Medicine, Shanghai, China
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8
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Bailly DK, Reeder RW, Winder M, Barbaro RP, Pollack MM, Moler FW, Meert KL, Berg RA, Carcillo J, Zuppa AF, Newth C, Berger J, Bell MJ, Dean JM, Nicholson C, Garcia-Filion P, Wessel D, Heidemann S, Doctor A, Harrison R, Bratton SL, Dalton H. Development of the Pediatric Extracorporeal Membrane Oxygenation Prediction Model for Risk-Adjusting Mortality. Pediatr Crit Care Med 2019; 20:426-434. [PMID: 30664590 PMCID: PMC6502677 DOI: 10.1097/pcc.0000000000001882] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To develop a prognostic model for predicting mortality at time of extracorporeal membrane oxygenation initiation for children which is important for determining center-specific risk-adjusted outcomes. DESIGN Multivariable logistic regression using a large national cohort of pediatric extracorporeal membrane oxygenation patients. SETTING The ICUs of the eight tertiary care children's hospitals of the Collaborative Pediatric Critical Care Research Network. PATIENTS Five-hundred fourteen children (< 19 yr old), enrolled with an initial extracorporeal membrane oxygenation run for any indication between January 2012 and September 2014. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 514 first extracorporeal membrane oxygenation runs were analyzed with an overall mortality of 45% (n = 232). Weighted logistic regression was used for model selection and internal validation was performed using cross validation. The variables included in the Pediatric Extracorporeal Membrane Oxygenation Prediction model were age (pre-term neonate, full-term neonate, infant, child, and adolescent), indication for extracorporeal membrane oxygenation (extracorporeal cardiopulmonary resuscitation, cardiac, or respiratory), meconium aspiration, congenital diaphragmatic hernia, documented blood stream infection, arterial blood pH, partial thromboplastin time, and international normalized ratio. The highest risk of mortality was associated with the presence of a documented blood stream infection (odds ratio, 5.26; CI, 1.90-14.57) followed by extracorporeal cardiopulmonary resuscitation (odds ratio, 4.36; CI, 2.23-8.51). The C-statistic was 0.75 (95% CI, 0.70-0.80). CONCLUSIONS The Pediatric Extracorporeal Membrane Oxygenation Prediction model represents a model for predicting in-hospital mortality among children receiving extracorporeal membrane oxygenation support for any indication. Consequently, it holds promise as the first comprehensive pediatric extracorporeal membrane oxygenation risk stratification model which is important for benchmarking extracorporeal membrane oxygenation outcomes across many centers.
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Affiliation(s)
- David K. Bailly
- Department of Pediatrics Division of Pediatric Critical
Care, University of Utah, Salt Lake City, UT
| | - Ron W. Reeder
- Department of Pediatrics Division of Pediatric Critical
Care, University of Utah, Salt Lake City, UT
| | - Melissa Winder
- Department of Pediatric Critical Care, Primary
Children’s Hospital, Salt Lake City, UT
| | - Ryan P. Barbaro
- Department of Pediatrics and Communicable Diseases,
University of Michigan, Ann Arbor, MI
| | - Murray M. Pollack
- Department of Pediatrics, Children’s National
Medical Center, Washington, DC
| | - Frank W. Moler
- Department of Pediatrics and Communicable Diseases,
University of Michigan, Ann Arbor, MI
| | - Kathleen L. Meert
- Department of Pediatrics, Children’s Hospital of
Michigan, Detroit, MI
| | - Robert A. Berg
- Department of Anesthesia and Critical Care,
Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Joseph Carcillo
- Department of Critical Care Medicine, Children’s
Hospital of Pittsburgh, Pittsburgh, PA
| | - Athena F. Zuppa
- Department of Anesthesia and Critical Care,
Children’s Hospital of Philadelphia, Philadelphia, PA
| | - Christopher Newth
- Department of Anesthesiology and Critical Care Medicine,
Children’s Hospital Los Angeles, Los Angeles, CA
| | - John Berger
- Department of Pediatrics, Children’s National
Medical Center, Washington, DC
| | - Michael J. Bell
- Department of Critical Care Medicine, Children’s
Hospital of Pittsburgh, Pittsburgh, PA
| | - J. Michael Dean
- Department of Pediatrics Division of Pediatric Critical
Care, University of Utah, Salt Lake City, UT
| | - Carol Nicholson
- Trauma and Critical Illness Branch, National Institute of
Child Health and Human Development NICHD, National Institutes of Health, Bethesda,
MD
| | | | - David Wessel
- Department of Pediatrics, Children’s National
Medical Center, Washington, DC
| | - Sabrina Heidemann
- Department of Pediatrics, Children’s Hospital of
Michigan, Detroit, MI
| | - Allan Doctor
- Departments of Pediatrics and Biochemistry, Washington
University, St. Louis, MO
| | - Rick Harrison
- Department of Pediatrics, Mattel Children’s
Hospital UCLA, Los Angeles, CA
| | - Susan L. Bratton
- Department of Pediatrics Division of Pediatric Critical
Care, University of Utah, Salt Lake City, UT
| | - Heidi Dalton
- Department of Pediatrics, Inova Fairfax Hospital, Fall
Church, VA
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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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10
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Bailly DK, Reeder RW, Zabrocki LA, Hubbard AM, Wilkes J, Bratton SL, Thiagarajan RR. Development and Validation of a Score to Predict Mortality in Children Undergoing Extracorporeal Membrane Oxygenation for Respiratory Failure: Pediatric Pulmonary Rescue With Extracorporeal Membrane Oxygenation Prediction Score. Crit Care Med 2017; 45:e58-e66. [PMID: 27548818 DOI: 10.1097/ccm.0000000000002019] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Our objective was to develop and validate a prognostic score for predicting mortality at the time of extracorporeal membrane oxygenation initiation for children with respiratory failure. Preextracorporeal membrane oxygenation mortality prediction is important for determining center-specific risk-adjusted outcomes and counseling families. DESIGN Multivariable logistic regression of a large international cohort of pediatric extracorporeal membrane oxygenation patients. SETTING Multi-institutional data. PATIENTS Prognostic score development: A total of 4,352 children more than 7 days to less than 18 years old, with an initial extracorporeal membrane oxygenation run for respiratory failure reported to the Extracorporeal Life Support Organization's data registry during 2001-2013 were used for derivation (70%) and validation (30%). Bidirectional stepwise logistic regression was used to identify factors associated with mortality. Retained variables were assigned a score based on the odds of mortality with higher scores indicating greater mortality. External validation was accomplished using 2,007 patients from the Pediatric Health Information System dataset. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The Pediatric Pulmonary Rescue with Extracorporeal Membrane Oxygenation Prediction score included mode of extracorporeal membrane oxygenation; preextracorporeal membrane oxygenation mechanical ventilation more than 14 days; preextracorporeal membrane oxygenation severity of hypoxia; primary pulmonary diagnostic categories including, asthma, aspiration, respiratory syncytial virus, sepsis-induced respiratory failure, pertussis, and "other"; and preextracorporeal membrane oxygenation comorbid conditions of cardiac arrest, cancer, renal and liver dysfunction. The area under the receiver operating characteristic curve for internal and external validation datasets were 0.69 (95% CI, 0.67-0.71) and 0.66 (95% CI, 0.63-0.69). CONCLUSIONS Pediatric Pulmonary Rescue with Extracorporeal Membrane Oxygenation Prediction is a validated tool for predicting in-hospital mortality among children with respiratory failure receiving extracorporeal membrane oxygenation support.
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Affiliation(s)
- David K Bailly
- 1Division of Pediatric Critical Care, Department of Pediatrics, Primary Children's Hospital, University of Utah, Salt Lake City, UT. 2Division of Pediatric Critical Care, Department of Pediatrics, Naval Medical Center San Diego, San Diego, CA. 3Department of Cardiology, Boston Children's Hospital, Boston, MA. 4Department of Pediatrics, Harvard Medical School, Boston, MA
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11
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Outcome Comparison in Children Undergoing Extracorporeal Life Support Initiated at a Local Hospital by a Mobile Cardiorespiratory Assistance Unit or at a Referral Center. Pediatr Crit Care Med 2016; 17:992-997. [PMID: 27705983 DOI: 10.1097/pcc.0000000000000897] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To compare characteristics and outcome in children undergoing extracorporeal life support initiated in an extracorporeal life support center or at the patient's bedside in a local hospital, by means of a mobile cardiorespiratory assistance unit. METHODS A retrospective study in a single PICU during 6 years. Extracorporeal life support was started either in our center (control group) or in the local hospital (mobile cardiorespiratory assistance unit group). The data collected were demographics, markers of patient's preextracorporeal life support condition, and outcome. RESULTS One hundred twenty-six children underwent extracorporeal life support, 105 in the control group and 21 in the mobile cardiorespiratory assistance unit group. There was no difference between groups in terms of age, weight, or Pediatric Risk of Mortality II score. There was a significant difference in organ failure etiology between groups, with more respiratory cases in the mobile cardiorespiratory assistance unit group (76.2%) and more cardiac surgery cases in the control group (60%; p < 0.001). The duration of extracorporeal life support was longer in the mobile cardiorespiratory assistance unit group than in the control group (10 [1-36] vs 5 [0-33] d; p = 0.003). PICU length of stay and mortality (60% vs 47.6%; p = 0.294) were not significantly different between the two groups. To allow comparison of a more homogenous population, a subgroup analysis was performed including only respiratory failure patients from the two groups (R-control group [n = 22] and R-mobile cardiorespiratory assistance unit group [n = 16]). PICU length of stay was 17 (3-64) days in the R-control group and 23 (1-45) days in the R-mobile cardiorespiratory assistance unit group (p = 0.564), and PICU mortality rate was 54.5% in the R-control group and 43.8% in the R-mobile cardiorespiratory assistance unit group (p = 0.511). There was no difference between the R-groups for age, weight, Pediatric Risk of Mortality II score, and markers of kidney or liver dysfunction, and lactate blood levels. CONCLUSION Extracorporeal life support can be safely initiated at children's bedside in the local hospital and then transported to the specialized referral center. Our results support the validity of an interregional organization of mobile cardiorespiratory assistance unit teams.
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Factors Associated With Mortality in Neonates Requiring Extracorporeal Membrane Oxygenation for Cardiac Indications: Analysis of the Extracorporeal Life Support Organization Registry Data. Pediatr Crit Care Med 2016; 17:860-70. [PMID: 27355824 DOI: 10.1097/pcc.0000000000000842] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Survival among neonates supported with extracorporeal membrane oxygenation for cardiac indications is 39%. Previous single-center studies have identified factors associated with mortality, but a comprehensive multivariate analysis is not available for this population. Understanding factors associated with mortality may help design treatment strategies, determine optimal timing for cannulation, and inform patient selection. This study identifies factors associated with mortality in neonates supported with extracorporeal membrane oxygenation for cardiac indications. DESIGN Retrospective cohort study. SETTING Two hundred and thirty U.S. and international centers reporting extracorporeal membrane oxygenation data to the Extracorporeal Life Support Organization. SUBJECTS Four thousand and four seventy one neonates with congenital and acquired cardiac disease supported with extracorporeal membrane oxygenation for cardiac indications during 2001-2011. INTERVENTIONS None. MEASUREMENTS AND RESULTS The primary outcome measure was mortality prior to hospital discharge. Overall hospital mortality was 59%. Demographic and preextracorporeal membrane oxygenation factors associated with mortality were evaluated in a multivariable model. Factors associated with death prior to hospital discharge included lower body weight, earlier era, single ventricle physiology, lower preextracorporeal membrane oxygenation arterial pH, and longer time from intubation to extracorporeal membrane oxygenation cannulation. Lower pH was associated with increased mortality regardless of cardiac diagnosis and surgical complexity. The majority of survivors separated from extracorporeal membrane oxygenation less than 8 days after extracorporeal membrane oxygenation deployment. CONCLUSIONS Mortality for neonates supported with extracorporeal membrane oxygenation for cardiac indications is high. Severity of preextracorporeal membrane oxygenation acidosis was independently associated with increased risk of mortality. Earlier initiation of extracorporeal membrane oxygenation may reduce the degree and duration of acidosis and may improve survival. Further studies are needed to determine optimal timing of cannulation in this population.
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Fan J, Chen ZY, Chen PY, Chen CH. [Application of ultrasonic cardiac output monitor in evaluation of cardiac function in children with severe pneumonia]. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2016; 18:817-820. [PMID: 27655536 PMCID: PMC7389972 DOI: 10.7499/j.issn.1008-8830.2016.09.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 06/27/2016] [Indexed: 06/06/2023]
Abstract
OBJECTIVE To study the clinical application of ultrasonic cardiac output monitor (USCOM) in evaluation of cardiac function in children with severe pneumonia. METHODS Twenty-nine children with severe pneumonia were enrolled in the observation group and forty-three children with common pneumonia were enrolled in the control group. The USCOM was used to measure the cardiac function indices in the two groups. The results were compared between the two groups. The changes in cardiac function indices after treatment were evaluated in the observation group. ESULTS The observation group had a significantly higher heart rate and significantly lower cardiac output, systolic volume, and aortic peak velocity than the control group (P<0.05). There were no significant differences in cardiac index or systemic vascular resistance between the two groups (P>0.05). In the observation group, the heart rate, cardiac output, systolic volume, aortic peak velocity, cardiac index, and systemic vascular resistance were significantly improved after treatment (P<0.05). CONCLUSIONS The USCOM is a fast, convenient, and accurate approach for dynamic measurement of cardiac function and overall circulation state in children with severe pneumonia. The USCOM can provide a basis for diagnosis, treatment, and evaluation of the disease, which is quite useful in clinical practice.
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Affiliation(s)
- Juan Fan
- Department of Pediatrics, Sichuan Academy of Medical Science/Sichuan Provincial People's Hospital, Chengdu 610072, China.
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High-frequency percussive ventilation and bronchoscopy during extracorporeal life support in children. ASAIO J 2015; 60:424-8. [PMID: 24830803 DOI: 10.1097/mat.0000000000000088] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Variables affecting duration of pediatric extracorporeal life support (ECLS) are poorly defined. Prior analyses suggested increased mortality risk with prolonged ECLS. Lung recruitment strategies with improved secretion mobilization may shorten ECLS duration. High frequency percussive ventilation (HFPV) has been used, predominantly in inhalational injury, as a mode of ventilation to improve secretion clearance. We describe the application of HFPV and therapeutic bronchoscopies in pediatric ECLS and evaluate outcomes with a same-center historical control population. After May 2011, all children (n = 14) on ECLS were managed with HFPV during extracorporeal support (HFPV cohort). This group's demographics and outcomes were compared with ECLS patients in our unit immediately before the utilization of HFPV (pre-HFPV cohort, n = 22). The HFPV and pre-HFPV cohorts had similar demographics and utilization of venoarterial ECLS. In univariate analysis, the HFPV group underwent more bronchoscopies and experienced more ECLS-free days (days alive and off ECLS) at 30 and 60 days. In multivariate analysis, use of HFPV was independently associated with ECLS-free days. We conclude that use of HFPV and bronchoscopies during ECLS for respiratory failure was associated with an increase in ECLS-free days and that this association should be prospectively evaluated.
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Bokman CL, Tashiro J, Perez EA, Lasko DS, Sola JE. Determinants of survival and resource utilization for pediatric extracorporeal membrane oxygenation in the United States 1997-2009. J Pediatr Surg 2015; 50:809-14. [PMID: 25783363 DOI: 10.1016/j.jpedsurg.2015.02.042] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2015] [Accepted: 02/13/2015] [Indexed: 11/25/2022]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) remains a vital therapy for children requiring cardiopulmonary support. METHODS The Kids' Inpatient Database (KID) was analyzed for ECMO (ICD-9-CM 39.65) patients between 1997 and 2009. RESULTS Overall, 8005 cases were identified, consisting of neonatal (ECMO <30days of life; 33%), infant (30days to 1year; 46%), young child (1year to 5years; 9.7%), and older child (>5years; 11%) groups. Patients were most commonly male (56%), Caucasian (49%), and insured by Medicaid (46%). ECMO was indicated for respiratory distress syndrome (RDS; 33%), cardiac and circulatory congenital anomalies (CCCA; 22%), congenital diaphragmatic hernia (CDH; 13%), and persistent pulmonary hypertension of the newborn (PPHN; 10%). On multivariate analysis, length of stay (LOS) decreased over the study period, while total charges (TC) increased over time, p<0.001. Survival was higher for boys and those treated in large or urban teaching hospitals, p<0.05. ECMO for CDH, CCCA, and RDS had the highest associated mortality, p<0.001. Neonatal and infant ECMO had no difference in mortality vs. older children. CONCLUSIONS While LOS for ECMO has decreased over time, TC has increased steadily. Improved survival is found in boys and patients at large or urban teaching hospitals. CDH, CCCA, and RDS portend poor survival outcomes as indicators for ECMO.
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Affiliation(s)
- Christine L Bokman
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Jun Tashiro
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Eduardo A Perez
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA
| | - David S Lasko
- South Florida Pediatric Surgeons P.A., Plantation, FL, USA
| | - Juan E Sola
- Division of Pediatric Surgery, DeWitt-Daughtry Family Department of Surgery, Leonard M. Miller School of Medicine, University of Miami, Miami, FL, USA.
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Improved oxygenation 24 hours after transition to airway pressure release ventilation or high-frequency oscillatory ventilation accurately discriminates survival in immunocompromised pediatric patients with acute respiratory distress syndrome*. Pediatr Crit Care Med 2014; 15:e147-56. [PMID: 24413319 PMCID: PMC4114308 DOI: 10.1097/pcc.0000000000000069] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Children with an immunocompromised condition and requiring invasive mechanical ventilation have high risk of death. Such patients are commonly transitioned to rescue modes of nonconventional ventilation, including airway pressure release ventilation and high-frequency oscillatory ventilation, for acute respiratory distress syndrome refractory to conventional ventilation. Our aim was to describe our experience with airway pressure release ventilation and high-frequency oscillatory ventilation in children with an immunocompromised condition and acute respiratory distress syndrome refractory to conventional ventilation and to identify factors associated with survival. DESIGN Retrospective cohort study. SETTING Tertiary care, university-affiliated PICU. PATIENTS Sixty pediatric patients with an immunocompromised condition and acute respiratory distress syndrome refractory to conventional ventilation transitioned to either airway pressure release ventilation or high-frequency oscillatory ventilation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Demographic data, ventilator settings, arterial blood gases, oxygenation index, and PaO(2)/FIO(2) were recorded before transition to either mode of nonconventional ventilation and at predetermined intervals after transition for up to 5 days. Mortality in the entire cohort was 63% and did not differ between patients transitioned to airway pressure release ventilation and high-frequency oscillatory ventilation. For both airway pressure release ventilation and high-frequency oscillatory ventilation, improvements in oxygenation index and PaO(2)/FIO(2) at 24 hours expressed as a fraction of pretransition values (oxygenation index(24)/oxygenation index(pre) and PaO(2)/FIO(224)/PaO(2)/FIO(2pre)) reliably discriminated nonsurvivors from survivors, with receiver operating characteristic areas under the curves between 0.89 and 0.95 (p for all curves < 0.001). Sensitivity-specificity analysis suggested that less than 15% reduction in oxygenation index (90% sensitive, 75% specific) or less than 90% increase in PaO(2)/FIO(2) (80% sensitive, 94% specific) 24 hours after transition to airway pressure release ventilation were the optimal cutoffs to identify nonsurvivors. The comparable values 24 hours after transition to high-frequency oscillatory ventilation were less than 5% reduction in oxygenation index (100% sensitive, 83% specific) or less than 80% increase in PaO(2)/FIO(2) (91% sensitive, 89% specific) to identify nonsurvivors. CONCLUSIONS In this single-center retrospective study of pediatric patients with an immunocompromised condition and acute respiratory distress syndrome failing conventional ventilation transitioned to either airway pressure release ventilation or high-frequency oscillatory ventilation, improved oxygenation at 24 hours expressed as PaO(2)/FIO(224)/PaO(2)/FIO(2pre) or oxygenation index(24)/oxygenation indexpre reliably discriminates nonsurvivors from survivors. These findings should be prospectively verified.
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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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