Initial experience with single-vessel cannulation for venovenous extracorporeal membrane oxygenation in pediatric respiratory failure

Device Related Thrombosis and Bleeding in Pediatric Health Care: A Meta-analysis

CONTEXT

The risk of invasive device-related thrombosis and bleeding contributes to morbidity and mortality, yet their prevalence by device-types is poorly understood.

OBJECTIVES

This study aimed to estimate pooled proportions and rates of thrombotic and bleeding complications associated with invasive devices in pediatric health care.

DATA SOURCES

Medline, CINAHL, Embase, Web of Science, Scopus, Cochrane CENTRAL, clinical trial registries, and unpublished study databases were searched.

STUDY SELECTION

Cohort studies and trials published from January 2011 to June 2022, including (1) indwelling invasive devices, (2) pediatric participants admitted to a hospital, (3) reporting thrombotic and bleeding complications, and (4) published in English, were included.

DATA EXTRACTION

Meta-analysis of observational studies in epidemiology guidelines for abstracting and assessing data quality and validity were used.

MAIN OUTCOMES AND MEASURES

Device-specific pooled thromboses (symptomatic, asymptomatic, unspecified) and bleeding (major, minor).

RESULTS

Of the 107 studies, 71 (66%) focused on central venous access devices. Symptomatic venous thromboembolism in central venous access devices was 4% (95% confidence interval [CI], 3-5; incidence rate 0.03 per 1000 device-days, 95% CI, 0.00-0.07), whereas asymptomatic was 10% (95% CI, 7-13; incidence rate 0.25 per 1000 device-days, 95% CI, 0.14-0.36). Both ventricular assist devices (28%; 95% CI, 19-39) and extracorporeal membrane oxygenation (67%; 95% CI, 52-81) were often associated with major bleeding complications.

CONCLUSIONS

This comprehensive estimate of the incidence and prevalence of device-related thrombosis and bleeding complications in children can inform clinical decision-making, guide risk assessment, and surveillance.

Strategies for appropriate positioning and repositioning the Avalon ECMO cannula in a 17-year-old with left hepatic vein malposition

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is a well-recognized therapy in children with refractory hypoxia. Different cannulas have been used with reported complications with placement, such as cardiac perforation, and multiple reports focusing on avoiding this. However, strategies to avoid hepatic vein cannulation and reposition when it occurs are not well described.

CASE REPORT

Here, we report a case where a 27-Fr Avalon bicaval double lumen cannula in the left hepatic vein was successfully repositioning using serial chest X-rays (CXR) and transthoracic echocardiography (TTE) in a 17-year-old female.

DISCUSSION

While venovenous (VV) ECMO is preferred by many, placement of the Avalon catheter, a cannula available for VV ECMO, may be challenging due to migration or positioning issues. Specific techniques of wire and catheter advancement as well as confirming wire position in the infra-hepatic inferior vena cava can help ensure appropriate positioning while avoiding hepatic vein cannulation and enabling successful repositioning when it occurs.

CONCLUSION

Wire position in the infra-hepatic inferior vena cava helps ensure safe and appropriate Avalon cannula position and placement. The Avalon cannula can be successfully repositioned from the left hepatic vein by retracting the cannula, reinserting the wire and introducer together, and then manipulation techniques using serial CXR and TTE.

Mortality after Lung Transplantation for Children Bridged with Extracorporeal Membrane Oxygenation

RATIONALE

Extracorporeal membrane oxygenation (ECMO) is increasingly used to bridge waitlisted children failing conventional respiratory support to lung transplantation.

OBJECTIVES

To compare in-hospital mortality and a composite outcome of 1-year mortality or re-transplantation in children bridged with ECMO with those on mechanical ventilation (MV), and neither support.

METHODS

The United Network for Organ Sharing (UNOS) was used to analyze lung transplant recipients, aged ≤ 20 y, from January 2004 to August 2019. Recipients were categorized according to level of respiratory support at time of transplant, including ECMO, MV, or neither. Multivariable analysis was used to evaluate support type and in-hospital mortality.

RESULTS

Of 1,014 children undergoing lung transplant, 68 (6.7%) required ECMO as a bridge-to-transplant, 144 (14.2%) MV, and 802 (79.1%) neither. Primary diagnosis in the ECMO cohort included cystic fibrosis (43%), pneumonia/ARDS (10.3%), interstitial pulmonary fibrosis (7.4%) and pulmonary hypertension (5.9%). Number of patients bridged with ECMO increased throughout the study period from none in 2004 to 16.7% in 2018. Multivariable analysis showed bridging with both ECMO (aOR = 3.57; 95% CI: 1.42, 8.97) and MV (aOR = 2.67; 95% CI: 1.26, 5.57) increased in-hospital mortality after lung transplantation. However, there was no difference in composite outcome of mortality and re-transplantation at 1-year between the three groups.

CONCLUSIONS

ECMO to bridge children to lung transplantation has increased. Despite this, ECMO is a high-risk bridge strategy for children awaiting lung transplantation. Future research should target interventions that can be focused on improving survival in these patients.

The Use of Intraoperative Peripheral Extracorporeal Membrane Oxygenation in High-Risk Airways Tumor Removal Procedures in Neonates and Children: A Single-Center Case Series

Airway surgery involving trachea or main stem bronchi in neonates and children is challenging. The use of extracorporeal support for such unusual indications is poorly described. Here, we report on three patients receiving peripheral extracorporeal membrane oxygenation (ECMO) to maintain adequate ventilation while improving surgical site exposure. Case 1 is a 9-year-old boy diagnosed with proximal left stem bronchus endoluminal tumor; cases 2 and 3 are a neonate and a young infant diagnosed with a subcarinal bronchogenic cyst. Planned ECMO use consisted in peripheral venoarterial cannulation through jugular and carotid access. There was no bleeding complication during and after surgical care. Hemodynamic and respiratory supports were optimized in all cases. Children were successfully weaned off ECMO immediately after surgery. Planned peripheral ECMO cannulation offers optimal conditions for high-risk airway surgery in neonates and children.

Inferior vena cava surgical cannulation for infants needing veno-venous extracorporeal membrane oxygenation

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.

Extracorporeal Membrane Oxygenation in Pediatric Patients with Respiratory Failure: Early Experience with the Double-Lumen Cannula Over 2 Years

Background

The double-lumen cannula (DLC) has begun to be used worldwide for venovenous (VV) extracorporeal membrane oxygenation (ECMO). We aimed to examine whether the DLC could be an effective tool in the treatment of pediatric respiratory failure in Korea.

Methods

We reviewed the records of patients weighing under 15 kg who underwent ECMO due to respiratory failure between January 2017 and December 2018. Outcomes of ECMO using a DLC and conventional ECMO using central method or 2 peripheral cannulas were compared.

Results

Twelve patients were treated with ECMO for respiratory failure. Among them, a DLC was used in 5 patients, the median age of whom was 3.8 months (interquartile range, 0.1–49.7 months). In these patients, the median values of pH, partial pressure of carbon dioxide, and partial pressure of oxygen were 7.09, 74 mm Hg, and 37 mm Hg before ECMO and corrected to 7.31, 44 mm Hg, and 85 mm Hg, respectively, after ECMO cannulation. Median blood flow rate in the patients treated with ECMO using a DLC was slightly higher than that in the conventional ECMO group, but this difference was not statistically significant (86.1 mL/kg/min and 74.3 mL/kg/min, respectively; p=1.00). One patient from the DLC group and 3 patients from the conventional group were weaned off ECMO.

Conclusion

VV ECMO using a DLC provided adequate oxygenation, ventilation, and blood flow rate in Korean pediatric patients with respiratory failure. Further prospective and randomized studies are warranted.

Illustration of the current practice and outcome comparison of early versus late tracheostomy after pediatric ECMO

OBJECTIVE

Pediatric extracorporeal membrane oxygenation typically necessitates protracted ventilator support, yet not much is known about the use of tracheostomy in the pediatric subpopulation. The study was designed with an objective to quantify the prevalence of tracheostomy in children with respiratory/cardiac failure requiring extracorporeal membrane oxygenation and to compare outcomes for patients undergoing early, late, and no tracheostomy.

METHODS

Data of patients <18 years of age who underwent extracorporeal membrane oxygenation for respiratory/cardiac failure between 2009 and 2015 were obtained from the Virtual Pediatric Systems (VPS, LLC) Database. Patients who underwent post-operative cardiac ECMO were excluded. Early versus late tracheostomy was defined as ⩽21 or >21 days after intensive care unit admission.

RESULTS

Data were analyzed for 2127 patients meeting inclusion and exclusion criteria. Five percent (107/2127) underwent a tracheostomy. Of these, 28% (30/107) underwent early and 72% (77/107) late tracheostomy. A higher mortality was found in the no tracheostomy group (41.3%) compared to early (13.3%) and late tracheostomy (14.3%) groups. Late tracheostomy was associated with 2.4 times the expected intensive care unit length of stay and 1.87 times the expected ventilator days as compared to patients with no tracheostomy. Early tracheostomy was associated with a shorter intensive care unit length of stay (p value < 0.001) and ventilator days (p value = 0.04) compared to late tracheostomy and no difference with the no tracheostomy group.

CONCLUSIONS

Late tracheostomy (>21 days) is associated with worse outcomes in the cohort of children who underwent Pediatric extracorporeal membrane oxygenation compared to patients who did not undergo tracheostomy. Early tracheostomy is associated with shorter intensive care unit stay and ventilator duration when compared to late tracheostomy.

Overview of the bicaval dual lumen cannula

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) is a form of extracorporeal life support that provides total gas exchange (CO2 and O2) within the central venous circulation. The bicaval dual lumen cannula (DLC) is an option for patients requiring respiratory support with VV-ECMO. The catheter is inserted via the internal jugular vein into the superior and inferior vena cava, drains blood into the ECMO circuit for gas exchange, and then returns arterialized blood to the right heart for circulation. The DLC facilitates physical therapy, ambulation, and early extubation. This chapter will review the uses, advantages, and unique complications of the DLC.

Pediatric extracorporeal membrane oxygenation: Our experience with single-vessel cannulation

Background

In this study, we present our experience with bicaval, dual-lumen, venovenous extracorporeal membrane oxygenation in pediatric patients with severe respiratory failure.

Methods

Between September 2015 and May 2019, a total of nine pediatric patients (7 males, 2 females; median age 3.1 years; range, 0.3 to 7.4 years) hospitalized in the pediatric intensive care unit due to severe respiratory failure who were cannulated using a bicaval, dual-lumen, venovenous catheter were retrospectively analyzed. Patient demographics, cannulation details, complication of catheter use, and outcomes were recorded.

Results

The median duration of extracorporeal membrane oxygenation support was nine (range, 2 to 32) days. One patient required conversion to venoarterial extracorporeal membrane oxygenation and one patient required conversion to conventional double-cannulated venovenous extracorporeal membrane oxygenation. Of the patients, 33% suffered from bleeding complications. There were no cannula- or circuit-related complications. Adequate oxygenation and flow were obtained in all patients, except one. No mortalities were directly associated with the cannulation strategy used.

Conclusion

The bicaval, dual-lumen cannula can be safely used in pediatric patients with minimal complication rates and is our preferred method for venovenous extracorporeal membrane oxygenation support.

Percutaneous bicaval dual lumen cannula for extracorporeal life support

Veno-venous extracorporeal membrane oxygenation (ECMO) is a useful mechanical device for pediatric patients with severe respiratory failure. Conventional veno-venous ECMO using double cannulation, however, is not feasible due to size limitations in pediatric patients who have small femoral vessels. Recently, percutaneous bicaval dual-lumen cannula can be inserted using single cannulation via the right internal jugular vein. Herein, we report the case of a pediatric patient with severe respiratory failure who was weaned off the ECMO successfully after treatment with bicaval dual-lumen cannulation for 5 days despite the small body size and immunocompromised condition due to chemotherapy for hemophagocytic lymphohistiocytosis.

Deep hypothermic extracorporeal membrane oxygenation cannula exchange in a child with necrotic pneumonia

Necrotizing pneumonia can lead to respiratory insufficiency in previously healthy children. Extracorporeal membrane oxygenation can be used for hemodynamic salvage and subsequent lung rest awaiting recovery. We present a case of a child initially placed on veno-arterial extracorporeal membrane oxygenation and converted to veno-venous extracorporeal membrane oxygenation. This was done under deep hypothermia in the operating theater.

Intensivists Performed Percutaneous Bicaval Double-Lumen Echo-Guided Extracorporeal Membrane Oxygenation Cannulation at Bedside in Newborns and Children: A Retrospective Analysis

OBJECTIVES

To describe a single institution experience on echo-guided percutaneous bicaval double lumen extracorporeal membrane oxygenation cannulation performed at the bedside by intensivists.

DESIGN

Retrospective observational study.

SETTING

Extracorporeal membrane oxygenation team of a tertiary care children's hospital.

PATIENTS

All patients 0-14 years old undergoing venovenous extracorporeal membrane oxygenation from January 1, 2013, to January 1, 2018.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Thirty children underwent 32 extracorporeal membrane oxygenation runs. Median age at enrollment was 2 months (interquartile range, 0-20.5 mo), 65.6% of the runs (21 patients) were performed in newborns (n = 13, 40.6%) or infants (n = 8, 25%). Median preextracorporeal membrane oxygenation index was 66.9 (interquartile range, 50-85.6). Major comorbidities were present in 50% of patients. All patients were cannulated percutaneously. In two cases cannulation occurred from the left internal jugular vein. Extracorporeal membrane oxygenation was effective in increasing pH, arterial oxygen saturation, PaO2, and lowering PaCO2. The overall differences in pre and postextracorporeal membrane oxygenation values were statistically significant, while stratifying patients according to the cannula diameter (mm)/major diameter of the cannulated internal jugular vein (mm) ratio (> 0.67 or ≤ 0.67), statistical significance was reached only for the highest ratio. Complications were observed in three runs: two cannula tip dislocations in the right atrium and one limited flow in the only case in which an Avalon cannula was not used. In 20 cases (62.5% of 32 runs), the cannulated vessel was patent at follow-up or autopsy. A ratio less than or equal to 0.67 or greater than 0.67 did not influence the occurrence rate of complications, nonpatency of the internal jugular vein, death for intracranial bleeding and death at 30 days from extracorporeal membrane oxygenation discontinuation. Overall cumulative survival at 30 days from extracorporeal membrane oxygenation discontinuation was 60% (95% CI, 40-75), with a survival advantage in the case of ratio greater than 0.67 (65%; 95% CI, 44-80 vs 25%; 95% CI, 0-60).

CONCLUSIONS

The described technique proved to be feasible, safe, and effective. Further investigation is needed.

Dynamic stenosis of the right main bronchus in a 3-month-old child: a tracheobronchial sleeve resection under venovenous extracorporeal membrane oxygenation

We report the case of a boy with congenital dynamic stenosis of the right main bronchus. The operation was postponed to a later date, when the patient was in a better clinical position to tolerate surgery. A tracheobronchial sleeve resection under dual-lumen venovenous extracorporeal membrane oxygenation was performed.

[Application of extracorporeal membrane oxygenation in children with acute respiratory distress syndrome]

The children with acute respiratory distress syndrome (ARDS) usually require ventilatory support treatment. At present, lung protective ventilation strategy is recommended for the treatment of ARDS. Extracorporeal membrane oxygenation (ECMO) can improve oxygenation and remove carbon dioxide by extracorporeal circuit, and can partially or completely take over cardiopulmonary function. ECMO support showed many advantages in treating severe ARDS, such as reducing ventilator-induced lung injury and correcting hypoxemia. Over the past few years, there has been an increase in the use of ECMO for ARDS in children. This paper reviews the applications of ECMO for the treatment of ARDS in children.

[Application of extracorporeal membrane oxygenation in children with acute respiratory distress syndrome]

The children with acute respiratory distress syndrome (ARDS) usually require ventilatory support treatment. At present, lung protective ventilation strategy is recommended for the treatment of ARDS. Extracorporeal membrane oxygenation (ECMO) can improve oxygenation and remove carbon dioxide by extracorporeal circuit, and can partially or completely take over cardiopulmonary function. ECMO support showed many advantages in treating severe ARDS, such as reducing ventilator-induced lung injury and correcting hypoxemia. Over the past few years, there has been an increase in the use of ECMO for ARDS in children. This paper reviews the applications of ECMO for the treatment of ARDS in children.

Use of venovenous ECMO for neonatal and pediatric ECMO: a decade of experience at a tertiary children's hospital

BACKGROUND

Advances in extracorporeal membrane oxygenation (ECMO) have led to increased use of venovenous (VV) ECMO in the pediatric population. We present the evolution and experience of pediatric VV ECMO at a tertiary care institution.

METHODS

A retrospective cohort study from 01/2005 to 07/2016 was performed, comparing by cannulation mode. Survival to discharge, complications, and decannulation analyses were performed.

RESULTS

In total, 160 patients (105 NICU, 55 PICU) required 13 ± 11 days of ECMO. VV cannulation was used primarily in 83 patients with 64% survival, while venoarterial (VA) ECMO was used in 77 patients with 54% survival. Overall, 74% of patients (n = 118) were successfully decannulated; 57% survived to discharge. VA ECMO had a higher rate of intra-cranial hemorrhage than VV (22 vs 9%, p = 0.003). Sixteen VA patients (21%) had radiographic evidence of a cerebral ischemic insult. No cardiac complications occurred with the use of dual-lumen VV cannulas. There were no differences in complications (p = 0.40) or re-operations (p = 0.85) between the VV and VA groups.

CONCLUSION

Dual-lumen VV ECMO can be safely performed with appropriate image guidance, is associated with a lower rate of intra-cranial hemorrhage, and may be the preferred first-line mode of ECMO support in appropriately selected NICU and PICU patients.

LEVEL OF EVIDENCE

II.

Avalon catheters in pediatric patients requiring ECMO: Placement and migration problems

PURPOSE

The Avalon dual-lumen venovenous catheter has several advantages, but placement techniques and management have not been adequately addressed in the pediatric population. We assessed our institutional outcomes and complications using the Avalon catheter in children.

METHODS

We reviewed all pediatric patients who had Avalon catheters placed for respiratory failure at our institution, excluding congenital heart disease patients, from April 2009 to March 2016. All patients were managed using our standard ECMO protocol, and cannula position was followed by daily chest x-ray and intermittent echocardiography (ECHO). Data included demographics, diagnosis, PRISM3 predicted mortality, ECMO duration, complications, and survival. The primary outcome was the need for catheter repositioning.

RESULTS

Twenty-five patients were included, with mean age 8.3±6.9years and 15±22days of ECMO support. Overall survival was 68% (17/25). Fourteen patients (56%) underwent placement with fluoroscopy in addition to ultrasound and ECHO, primarily after 2013. Overall, thirteen patients (52%) had problems with cannula malposition. 9 of these (69%) required cannula repositioning. Three of 14 (21%) cannulas placed with fluoroscopy required repositioning, compared to 7/11 (64%) placed without fluoroscopy (p=0.05).

CONCLUSIONS

Complications are common with the Avalon catheter in children. Safe percutaneous access requires ultrasound guidance, and use of intraoperative fluoroscopy in addition to echocardiography decreases malposition rates.

LEVEL OF EVIDENCE

IV (Prognosis study).

Extracorporeal Life Support: Four Decades and Counting

Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) is a form of heart lung bypass that is used to support neonates, pediatrics, and adult patients with cardiorespiratory failure for days or weeks till organ recovery or transplantation. Venoarterial (VA) and venovenous (VV) ECLS are the most common modes of support. ECLS circuit components and monitoring have been evolving over the last 40 years. The technology is safer, simpler, and more durable with fewer complications. The use of neonatal respiratory ECLS use has been declining over the last two decades, while adult respiratory ECLS is growing especially since the H1N1 influenza pandemic in 2009. This review provides an overview of ECLS evolution over the last four decades, its use in neonatal, pediatric and adults, description of basic principles, circuit components, complications, and outcomes as well as a quick look into the future.

Neonatal Extracorporeal Membrane Oxygenation: Update on Management Strategies and Long-Term Outcomes

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) can be deployed to support patients with severe cardiorespiratory failure unresponsive to conventional medical interventions. Neonatal trials have demonstrated that ECMO is an effective treatment of severe respiratory failure, with acceptable cognitive and functional outcomes. Technological advances in ECMO have resulted in improved safety and accessibility, contributing to decreased morbidity and improved survival of increasingly complex patients requiring ECMO support.

PURPOSE

This review aims to describe the innovations in ECMO technology and management in the neonatal population in the last decade. The long-term outcomes of neonatal patients requiring ECMO support will be discussed.

SEARCH STRATEGY

Relevant clinical trials from MEDLINE and the Cochrane Library were identified. The following key words were used: ECMO, infant, neonate, and outcomes.

FINDINGS

Challenges still remain in supporting the premature and/or low-birth-weight infant with severe respiratory failure, as well as infants with congenital diaphragmatic hernia. Neonatal ECMO survivors can present with neurodevelopmental and respiratory problems, which become more prominent with time.

IMPLICATIONS FOR PRACTICE

While newer technologies have led to fewer neonates with respiratory failure progressing to ECMO, it remains an important tool to in those who have failed conventional therapies. Given the presence of neurodevelopmental problems in neonatal ECMO survivors, multidisciplinary follow-up targeting motor performance, exercise capacity, behavior, and subtle learning deficits is warranted.

IMPLICATIONS FOR RESEARCH

With the overall decreasing use of neonatal ECMO, ECMO centers must find ways to maintain their expertise in the light of lower patient volumes amidst complex patient physiology.

Emergency percutaneous, bicaval double-lumen, ECMO cannulation in neonates and infants: insights from three consecutive cases

BACKGROUND

Veno-venous extracorporeal membrane oxygenation (ECMO) is probably the preferable configuration to assist children with respiratory failure who do not respond to maximized conventional therapies. The single-vessel, double-lumen approach through the internal jugular vein is extremely advantageous, especially in infants, where femoral access presents limitations related to the small dimensions of the veins. In case of emergencies, ECMO might need to be started at the bedside, without the availability of fluoroscopic guidance. To our knowledge, a completely percutaneous approach has not been reported before in children younger than 1 year and weighing less than 5 kg.

METHODS

We describe 3 cases of emergency bedside, percutaneous, bicaval double-lumen cannulation under real-time transthoracic ultrasound control in 2 neonates and 1 infant.

RESULTS

In our experience, this approach proved to be safe, effective and time saving, while minimizing bleeding from the cannula insertion site. Cannulation times, from decision making to the beginning of ECMO flow, were 30, 28, 25 minutes respectively, from patient 1 to 3. We do not report any cannula-related injury to vessels and heart structures.

CONCLUSIONS

Our preliminary data suggest that, with the described precautions, percutaneous, echo-guided, bicaval double-lumen cannulation in neonates and infants could be effective and free from major complications. Further evaluation should be warranted in the neonatal population.

Extracorporeal life support: experience with 2,000 patients

This is a review of the University of Michigan experience with extracorporeal life support (ECLS) also known as extracorporeal membrane oxygenation (ECMO). Two thousand patients were managed with ECMO from 1973 to 2010. The first 1,000 patients were reported previously. Of the 2,000 patients, 74% were weaned from ECLS, and 64% survived to hospital discharge. In patients with respiratory failure, survival to hospital discharge was 84% in 799 neonates, 76% in 239 children, and 50% in 353 adults. Survival in patients with cardiac failure was 45% in 361 children and 38% in 119 adults. ECLS during extracorporeal cardiopulmonary resuscitation was performed in 129 patients, with 41% surviving to discharge. Survival decreased from 74 to 55% between the first and second 1,000 patients. The most common complication was bleeding at sites other than the head, with an incidence of 39%, and the least frequent complication was pump malfunction, with a 2% incidence. Intracranial bleeding or infarction occurred in 8% of patients, with a 43% survival rate. This is the largest series of ECLS at one institution reported in the world to date. Our experience has shown that ECLS saves lives of moribund patients with acute pulmonary and cardiac failure in all age groups.

Acute respiratory distress syndrome in a child with severe epileptic disorder treated successfully by extracorporeal membrane oxygenation: a case report

BACKGROUND

Extracorporeal membrane oxygenation (ECMO) is now a candidate therapy for children with acute respiratory failure.

CASE PRESENTATION

We report our experience of using central ECMO therapy for acute respiratory distress syndrome followed by seizure in a 15-month-old girl with a severe epileptic disorder. Her respiratory distress was refractory to standard medical treatment and mechanical ventilatory support. Her condition was complicated by development of a pneumothorax. The patient was successfully weaned off ECMO and discharged without deterioration of her neurological status.

CONCLUSION

The successful outcome in this case resulted from the central ECMO, which enabled "lung rest" and adequate cerebral blood flow. In skilled ECMO facilities, early implementation of ECMO would give some advantages to patients such as the one presented here. Given the invasiveness and the ease of the procedure, introduction of dual-lumen catheters adequately sized for pediatric patients in Japan is required.

Outcomes comparing dual-lumen to multisite venovenous ECMO in the pediatric population: the Extracorporeal Life Support Registry experience

PURPOSE

The purpose of this study is to evaluate outcomes associated with single site dual-lumen venovenous cannulas (VVDL) and to compare them to those associated with multisite VV ECMO (VVMS) cannulation.

METHODS

The Extracorporeal Life Support (ELSO) Registry was reviewed to identify all children 31days to 18years treated with venovenous ECMO from 1998 to 2011 using either VVDL or VVMS techniques. Patient demographics, cannula type, ECMO variables, complications, and patient survival were analyzed.

RESULTS

From 1998 to 2011, 1323 children underwent venovenous ECMO. The annual utilization of VVDL cannulas has increased and recently surpassed VVMS. Fifty-four percent (n=717) of patients had VVDL cannulation. This group was significantly younger and weighed less than the VVMS group. VVDL cannulas demonstrated improved weight-adjusted flow performance than traditional cannulation. Overall survival was comparable, 64.4% and 68.6%, for VVMS and VVDL respectively. VVDL cannulas experienced higher mechanical (26.2% vs. 22.5%; p=0.004) and cardiovascular complications rates (24.4% vs. 21.7%; p=0.03) than VVMS cannulas, but when stratified by VVDL cannula type, there were no differences between wire-reinforced and non-wire reinforced cannulas.

CONCLUSIONS

VVDL cannulation has become the preferred modality for ECMO therapy in children with respiratory failure and it is mainly utilized in younger patients. The use of newer VVDL cannulas may provide improved pump flow performance without substantial additional risk.

Experience with the Avalon® bicaval double-lumen veno-venous cannula for neonatal respiratory ECMO

OBJECTIVE

We report a single centre experience of neonatal respiratory ECMO using the Avalon® double-lumen venous cannula and compare it with reports in the literature.

RESULTS

Between 2008 and 2012, the Avalon® cannula was used in 72 neonates: median age at cannulation was 1.8 days (IQR 1.2-2.8 days) and bodyweight 3.4 Kg (3.0-3.7 Kg). Meconium aspiration syndrome (61.1%), persistent hypertension of the newborn (25%) and congenital diaphragmatic hernia (5.6%) were the most common diagnoses. Complications occurred in 19 patients (26.4%): cannula site bleeding in 6 (8.3%), the cannula perforating the right atrial wall and requiring emergency midline sternotomy in 5 (6.9%) and the cannula needing repositioning in 3 (4.2%). Overall survival at discharge or transfer to the referring hospital was 88.8%. Successful wean off ECMO occurred in 68 patients (94.4%) after a median of 90.5 hours (63.4-136.11). ECMO support was withdrawn in 4 patients (5.6%).

CONCLUSIONS

The Avalon® dual-lumen veno-venous cannula can be used for respiratory ECMO in the neonatal population. However, as the incidence of right atrial perforation is not negligible, we suspended its used in this group of patients.

Extracorporeal membrane oxygenation for pediatric respiratory failure: History, development and current status

Extracorporeal membrane oxygenation (ECMO) is currently used to support patients of all ages with acute severe respiratory failure non-responsive to conventional treatments, and although initial use was almost exclusively in neonates, use for this age group is decreasing while use in older children remains stable (300-500 cases annually) and support for adults is increasing. Recent advances in technology include: refinement of double lumen veno-venous (VV) cannulas to support a large range of patient size, pumps with lower prime volumes, more efficient oxygenators, changes in circuit configuration to decrease turbulent flow and hemolysis. Veno-arterial (VA) mode of support remains the predominant type used; however, VV support has lower risk of central nervous injury and mortality. Key to successful survival is implementation of ECMO before irreversible organ injury develops, unless support with ECMO is used as a bridge to transplant. Among pediatric patients treated with ECMO mortality varies by pulmonary diagnosis, underlying condition, other non-pulmonary organ dysfunction as well as patient age, but has remained relatively unchanged overall (43%) over the past several decades. Additional risk factors associated with death include prolonged use of mechanical ventilation (> 2 wk) prior to ECMO, use of VA ECMO, older patient age, prolonged ECMO support as well as complications during ECMO. Medical evidence regarding daily patient management specifically related to ECMO is scant, it usually mirrors care recommended for similar patients treated without ECMO. Linkage of the Extracorporeal Life Support Organization dataset with other databases and collaborative research networks will be required to address this knowledge deficit as most centers treat only a few pediatric respiratory failure patients each year.

[Particularities of ECMO in acute respiratory distress syndrome in pediatrics]

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.