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Mattke AC, Johnson K, Gibbons K, Long D, Robertson J, Venugopal PS, Blumenthal A, Schibler A, Schlapbach L. Nitric Oxide on Extracorporeal Membrane Oxygenation in Neonates and Children (NECTAR Trial): Protocol for a Randomized Controlled Trial. JMIR Res Protoc 2023; 12:e43760. [PMID: 36920455 PMCID: PMC10131908 DOI: 10.2196/43760] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/11/2023] [Accepted: 01/28/2023] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) provides support for the pulmonary or cardiovascular function of children in whom the predicted mortality risk remains very high. The inevitable host inflammatory response and activation of the coagulation cascade due to the extracorporeal circuit contribute to additional morbidity and mortality in these patients. Mixing nitric oxide (NO) into the sweep gas of ECMO circuits may reduce the inflammatory and coagulation cascade activation during ECMO support. OBJECTIVE The purpose of this study is to test the feasibility and safety of mixing NO into the sweep gas of ECMO systems and assess its effect on inflammation and coagulation system activation through a pilot randomized controlled trial. METHODS The Nitric Oxide on Extracorporeal Membrane Oxygenation in Neonates and Children (NECTAR) trial is an open-label, parallel-group, pilot randomized controlled trial to be conducted at a single center. Fifty patients who require ECMO support will be randomly assigned to receive either NO mixed into the sweep gas of the ECMO system at 20 ppm for the duration of ECMO or standard care (no NO) in a 1:1 ratio, with stratification by support type (veno-venous vs veno-arterial ECMO). RESULTS Outcome measures will focus on feasibility (recruitment rate and consent rate, and successful inflammatory marker measurements), the safety of the intervention (oxygenation and carbon dioxide control within defined parameters and methemoglobin levels), and proxy markers of efficacy (assessment of cytokines, chemokines, and coagulation factors to assess the impact of NO on host inflammation and coagulation cascade activation, clotting of ECMO components, including computer tomography scanning of oxygenators for clot assessments), bleeding complications, as well as total blood product use. Survival without ECMO and the length of stay in the pediatric intensive care unit (PICU) are clinically relevant efficacy outcomes. Long-term outcomes include neurodevelopmental assessments (Ages and Stages Questionnaire, Strength and Difficulties Questionnaire, and others) and quality of life (Pediatric Quality of Life Inventory and others) measured at 6 and 12 months post ECMO cannulation. Analyses will be conducted on an intention-to-treat basis. CONCLUSIONS The NECTAR study investigates the safety and feasibility of NO as a drug intervention during extracorporeal life support and explores its efficacy. The study will investigate whether morbidity and mortality in patients treated with ECMO can be improved with NO. The intervention targets adverse outcomes in patients who are supported by ECMO and who have high expected mortality and morbidity. The study will be one of the largest randomized controlled trials performed among pediatric patients supported by ECMO. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12619001518156; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=376869. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/43760.
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Affiliation(s)
- Adrian C Mattke
- Paediatric Intensive Care Unit, Children's Health Queensland, Queensland Children's Hospital, South Brisbane, Australia.,School of Medicine, University of Queensland, Herston, Australia.,Child Health Research Centre, The University of Queensland, South Brisbane, Australia
| | - Kerry Johnson
- Paediatric Intensive Care Unit, Children's Health Queensland, Queensland Children's Hospital, South Brisbane, Australia.,Child Health Research Centre, The University of Queensland, South Brisbane, Australia
| | - Kristen Gibbons
- Child Health Research Centre, The University of Queensland, South Brisbane, Australia
| | - Debbie Long
- School of Nursing, Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia
| | - Jeremy Robertson
- Paediatric Haematology and Haemophilia Service, Queensland Children's Hospital, South Brisbane, Australia
| | - Prem S Venugopal
- School of Medicine, University of Queensland, Herston, Australia.,Department for Cardiac Surgery, Queensland Children's Hospital, Children's Health Queensland, South Brisbane, Australia
| | - Antje Blumenthal
- Frazer Institute, The University of Queensland, Brisbane, Australia
| | | | - Luregn Schlapbach
- School of Medicine, University of Queensland, Herston, Australia.,University Children's Hospital Zurich, University of Zurich, Zurich, Switzerland
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Boeken U, Assmann A, Beckmann A, Schmid C, Werdan K, Michels G, Miera O, Schmidt F, Klotz S, Starck C, Pilarczyk K, Rastan A, Burckhardt M, Nothacker M, Muellenbach R, Zausig Y, Haake N, Groesdonk H, Ferrari M, Buerke M, Hennersdorf M, Rosenberg M, Schaible T, Köditz H, Kluge S, Janssens U, Lubnow M, Flemmer A, Herber-Jonat S, Wessel L, Buchwald D, Maier S, Krüger L, Fründ A, Jaksties R, Fischer S, Wiebe K, Hartog CS, Dzemali O, Zimpfer D, Ruttmann-Ulmer E, Schlensak C, Kelm M, Ensminger S. S3 Guideline of Extracorporeal Circulation (ECLS/ECMO) for Cardiocirculatory Failure. Thorac Cardiovasc Surg 2021; 69:S121-S212. [PMID: 34655070 DOI: 10.1055/s-0041-1735490] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Udo Boeken
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Alexander Assmann
- Department of Cardiac Surgery, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Andreas Beckmann
- German Society for Thoracic and Cardiovascular Surgery, Langenbeck-Virchow-Haus, Berlin, Germany
| | - Christof Schmid
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Karl Werdan
- Clinic for Internal Medicine III, University Hospital Halle (Saale), Martin-Luther University Halle-Wittenberg, Germany
| | - Guido Michels
- Department of Acute and Emergency Care, St Antonius Hospital Eschweiler, Eschweiler, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Florian Schmidt
- Department of Pediatric Cardiology and Intensive Care Medicine, Medical School Hannover, Hannover, Germany
| | - Stefan Klotz
- Department of Cardiac Surgery, Segeberger Kliniken, Bad Segeberg, Germany
| | - Christoph Starck
- Department of Cardiothoracic and Vascular Surgery, German Heart Centre, Berlin, German
| | - Kevin Pilarczyk
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Ardawan Rastan
- Department of Cardiac and Vascular Thoracic Surgery, Philipps-University Hospital Marburg, Marburg, Germany
| | - Marion Burckhardt
- Department of Health Sciences and Management; Baden-Wuerttemberg Cooperative State University (DHBW), Stuttgart, Germany
| | - Monika Nothacker
- Institute for Medical Knowledge Management, Association of the Scientific Medical Societies (AWMF), Universität Marburg, Marburg, Germany
| | - Ralf Muellenbach
- Department of Anaesthesiology and Critical Care Medicine, Campus Kassel of the University of Southampton, Kassel, Germany
| | - York Zausig
- Department of Anesthesiology and Operative Intensive Care Medicine, Aschaffenburg-Alzenau Hospital, Aschaffenburg, Bavaria, Germany
| | - Nils Haake
- Department for Intensive Care Medicine, Imland Hospital Rendsburg, Rendsburg, Schleswig-Holstein, Germany
| | - Heinrich Groesdonk
- Department of Intensive Care Medicine, Helios Clinic Erfurt, Erfurt, Germany
| | - Markus Ferrari
- HSK, Clinic of Internal Medicine I, Helios-Kliniken, Wiesbaden, Germany
| | - Michael Buerke
- Department of Cardiology, Angiology and Intensive Care Medicine, St. Marienkrankenhaus Siegen, Siegen, Germany
| | - Marcus Hennersdorf
- Department of Cardiology, Pneumology, Angiology and Internal Intensive Care Medicine, SLK-Kliniken Heilbronn, Heilbronn, Germany
| | - Mark Rosenberg
- Klinikum Aschaffenburg-Alzenau, Medizinische Klinik 1, Aschaffenburg, Germany
| | - Thomas Schaible
- Department of Neonatology, University Children's Hospital Mannheim, University of Heidelberg, Mannheim, Germany
| | - Harald Köditz
- Medical University Children's Hospital, Hannover, Germany
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St Antonius Hospital, Eschweiler, Germany
| | - Matthias Lubnow
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
| | - Andreas Flemmer
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Munich, Germany
| | - Susanne Herber-Jonat
- Division of Neonatology, Dr. v. Hauner Children's Hospital and Perinatal Center Munich - Grosshadern, LMU Munich, Germany
| | - Lucas Wessel
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Dirk Buchwald
- Department of Pediatric Surgery, Medical Faculty Mannheim, University of Heidelberg, Germany
| | - Sven Maier
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
| | - Lars Krüger
- Division of Thoracic and Cardiovascular Surgery, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | - Andreas Fründ
- Department of Physiotherapy, Heart- and Diabetescentre NRW, Ruhr-University, Bochum, Germany
| | | | - Stefan Fischer
- Department of Thoracic Surgery and Lung Support, Ibbenbueren General Hospital, Ibbenbueren, Germany
| | - Karsten Wiebe
- Department of Cardiothoracic Surgery, Münster University Hospital, Münster, Germany
| | - Christiane S Hartog
- Department of Anesthesiology and Operative Intensive Care Medicine, Charité Universitätsmedizin Berlin, and Klinik Bavaria, Kreischa
| | - Omer Dzemali
- Department of Cardiac Surgery, Triemli City hospital Zurich, Zurich, Switzerland
| | - Daniel Zimpfer
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Christian Schlensak
- Department of Cardio-Thoracic and Vascular Surgery, University of Tübingen, Tübingen, Germany
| | - Malte Kelm
- Department of Cardiology, Pulmonology and Vascular Medicine, Heinrich-Heine-University Medical School, Duesseldorf, Germany
| | - Stephan Ensminger
- Department of Cardiac and Thoracic Vascular Surgery, University Hospital of Schleswig-Holstein, Lübeck, Germany
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Sommer W, Warnecke G. Lung transplantation for pediatric pulmonary arterial hypertension-quo vadis? Cardiovasc Diagn Ther 2021; 11:1178-1189. [PMID: 34527542 DOI: 10.21037/cdt-21-65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 06/23/2021] [Indexed: 11/06/2022]
Abstract
In children with pulmonary arterial hypertension, lung transplantation illustrates a feasible treatment option once pharmacological therapy is exhausted. Timing of listing for lung transplantation in children remains difficult since hemodynamic deterioration often occurs abruptly and the time on the waiting list is usually hard to predict. Clear contraindications for lung transplantation are recent history of malignancies as well as irreversible end-organ failure. Generally, patients with pulmonary arterial hypertension in the absence of structural cardiac defects can safely undergo bilateral lung transplantation, combined heart-lung transplantation remains a procedure with a higher perioperative risk and should only be performed in selected cases with irreversible structural defects. Donor selection in recent years shows donors with extended criteria as well as lobar transplantation with good outcome, having the positive effect of broadening of the donor pool. Bridging to lung transplantation with veno-arterial ECMO treatment is feasible and has a good outcome in experienced transplant centers. Surgical considerations should include the risk of hemodynamic decompensation upon anesthesia induction and the need for extracorporeal support pre-, intra- and postoperative. Lung transplantation should be performed on veno-arterial ECMO support with either peripheral (>20 kg) or central cannulation (<20 kg). The surgical transplantation procedure includes the bronchial anastomosis as well as anastomoses of the pulmonary artery and the left atrium. Postoperative prolonged veno-arterial ECMO treatment for the immediate postoperative period allows for left ventricular remodeling given the new hemodynamic circumstances with lower pulmonary vascular resistance. Standard triple immunosuppression in most lung transplant programs currently includes steroids, mycophenolate mofetil and tacrolimus. Survival after pediatric lung transplantation for IPAH is comparable to pediatric lung transplants for other underlying diseases with a 1-year survival of approx. 80% and a 5-year survival of 64-65%. Therefore, evolving techniques in the field of lung transplantation led to overall improved survival prospects in children with end-stage pulmonary vascular disease.
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Affiliation(s)
- Wiebke Sommer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
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Doo I, Staub LP, Mattke A, Haisz E, Seidler AL, Alphonso N, Schlapbach LJ. Diagnostic Accuracy of Infection Markers to Diagnose Infections in Neonates and Children Receiving Extracorporeal Membrane Oxygenation. Front Pediatr 2021; 9:824552. [PMID: 35155322 PMCID: PMC8826436 DOI: 10.3389/fped.2021.824552] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 12/20/2021] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Infections represent one of the most common complications in patients managed on Extracorporeal Membrane Oxygenation (ECMO) and are associated with poorer outcomes. Clinical signs of infection in patients on ECMO are non-specific. We assessed the diagnostic accuracy of Procalcitonin (PCT), C-reactive protein (CRP) and White cell count (WCC) to diagnose infection on ECMO. METHODS Retrospective single center observational study including neonates and children <18 years treated with ECMO in 2015 and 2016. Daily data on PCT, CRP and WCC were assessed in relation to microbiologically confirmed, and clinically suspected infection on ECMO using operating characteristics (ROC) curves. RESULTS Sixty-five ECMO runs in 58 patients were assessed. CRP had the best accuracy with an area under the ROC curve (AUC) of 0.79 (95%-CI 0.66-0.92) to diagnose confirmed infection and an AUC of 0.72 (0.61-0.84) to diagnose confirmed and suspected infection. Abnormal WCC performed slightly worse with an AUC of 0.70 (0.59-0.81) for confirmed and AUC of 0.66 (0.57-0.75) for confirmed and suspected infections. PCT was non-discriminatory. CONCLUSION The diagnosis of infections acquired during ECMO remains challenging. Larger prospective studies are needed that also include novel infection markers to improve recognition of infection in patients on ECMO.
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Affiliation(s)
- Irene Doo
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Lukas P Staub
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Adrian Mattke
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Emma Haisz
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia
| | - Anna Lene Seidler
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Sydney, NSW, Australia
| | - Nelson Alphonso
- Queensland Paediatric Cardiac Service, Queensland Children's Hospital, Brisbane, QLD, Australia
| | - Luregn J Schlapbach
- Paediatric Intensive Care Unit, Queensland Children's Hospital, Brisbane, QLD, Australia.,Child Health Research Centre, The University of Queensland, Brisbane, QLD, Australia.,Department of Intensive Care Medicine and Neonatology, and Children's Research Center, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
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5
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Abstract
BACKGROUND The perioperative complications rate in paediatric cardiac surgery, as well as the failure-to-rescue impact, is less known in low- and middle-income countries. AIM To evaluate perioperative complications rate, mortality related to complications, different patients' demographics, and procedural risk factors for perioperative complication and post-operative death. METHODS Risk factors for perioperative complications and operative mortality were assessed in a retrospective single-centre study which included 296 consecutive children undergoing cardiac surgery. RESULTS Overall mortality was 5.7%. Seventy-three patients (24.7%) developed 145 perioperative complications and had 17 operative mortalities (23.3%). There was a strong association between the number of perioperative complications and mortality - 8.1% among patients with only 1 perioperative complication, 35.3% - with 2 perioperative complications, and 42.1% - with 3 or more perioperative complications (p = 0.007). Risk factors of perioperative complications were younger age (odds ratio 0.76; (95% confidence interval 0.61, 0.93), previous cardiac surgery (odds ratio 3.5; confidence interval 1.33, 9.20), extracardiac structural anomalies (odds ratio 3.03; confidence interval 1.27, 7.26), concomitant diseases (odds ratio 3.23; confidence interval 1.34, 7.72), and cardiopulmonary bypass (odds ratio 6.33; confidence interval 2.45, 16.4), whereas the total number of perioperative complications per patient was the only predictor of operative death (odds ratio 1.89; confidence interval 1.06, 3.37). CONCLUSIONS In a program with limited systemic resources, failure-to-rescue is a major contributor to operative mortality in paediatric cardiac surgery. Despite the comparable crude mortality, the operative mortality among patients with perioperative complications in our series was significantly higher than in the developed world. A number of initiatives are needed in order to improve failure-to-rescue rates in low- and middle-income countries.
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Solé A, Jordan I, Bobillo S, Moreno J, Balaguer M, Hernández-Platero L, Segura S, Cambra FJ, Esteban E, Rodríguez-Fanjul J. Venoarterial extracorporeal membrane oxygenation support for neonatal and pediatric refractory septic shock: more than 15 years of learning. Eur J Pediatr 2018; 177:1191-1200. [PMID: 29799085 DOI: 10.1007/s00431-018-3174-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/05/2018] [Accepted: 05/10/2018] [Indexed: 12/29/2022]
Abstract
UNLABELLED The objective of the study was to report our institutional experience in the management of children and newborns with refractory septic shock who required venoarterial extracorporeal membrane oxygenation (VA ECMO) treatment, and to identify patient-and infection-related factors associated with mortality. This is a retrospective case series in an intensive care unit of a tertiary pediatric center. Inclusion criteria were patients ≤ 18 years old who underwent a VA ECMO due to a refractory septic shock due to circulatory collapse. Patient conditions and support immediately before ECMO, analytical and hemodynamic parameter evolution during ECMO, and post-canulation outcome data were collected. Twenty-one patients were included, 13 of them (65%) male. Nine were pediatric and 12 were newborns. Median septic shock duration prior to ECMO was 29.5 h (IQR, 20-46). Eleven patients (52.4%) suffered cardiac arrest (CA). Neonatal patients had worse Sepsis Organ Failure Assessment (SOFA) score, Oxygenation Index and PaO2/FiO2 ratio, blood gas analysis, lactate levels, and left ventricular ejection fraction compared to pediatric patients. Survival was 33.3% among pediatric patients (60% if we exclude pneumococcal cases) and 50% among newborns. Hours of sepsis evolution and mean airway pressure (MAP) prior to ECMO were significantly higher in the non-survivor group. CA was not a predictor of mortality. Streptococcus pneumoniae infection was a mortality risk factor. There was an improvement in survival during the second period, from 14.3 to 57.2%, related to shorter sepsis evolution before ECMO placement, better candidate selection, and greater ECMO support once the patient was placed. CONCLUSION Patients with refractory septic shock should be transferred precociously to a referral ECMO center. However, therapy should be used with caution in patients with vasoplegic pattern shock or S. pneumoniae sepsis. What is Known: • Children with refractory septic shock have significant mortality rates, and although ECMO is recommended, overall survival is low. • There are no studies regarding characteristics of infections as predictors of pediatric survival in ECMO. What is New: • Septic children should be transferred precociously to referral ECMO centers during the first hours if patients do not respond to conventional therapy. • Treatment should be used with caution in patients with vasoplegic pattern shock or S. pneumoniae sepsis.
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Affiliation(s)
- Anna Solé
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Iolanda Jordan
- Pediatric Intensive Care Unit, Sant Joan de Déu Hospital, Paediatric Infectious Diseases Research Group, Institut Recerca Hospital Sant Joan de Déu, CIBERESP, Barcelona, Spain
| | - Sara Bobillo
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Julio Moreno
- Neonatal Intensive Care Unit Service, Hospital de Sant Joan de Déu Maternal, Fetal and Neonatology Center Barcelona (BCNatal), University of Barcelona, Barcelona, Spain
| | - Monica Balaguer
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Lluisa Hernández-Platero
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Susana Segura
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Francisco José Cambra
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Elisabeth Esteban
- Pediatric Intensive Care Unit Service, Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Javier Rodríguez-Fanjul
- Neonatal Intensive Care Unit Service, Hospital de Sant Joan de Déu Maternal, Fetal and Neonatology Center Barcelona (BCNatal), University of Barcelona, Barcelona, Spain. .,Pediatric Emergency Transport, Servei Emergències Mèdiques (SEM), Hospital de Sant Joan de Déu, University of Barcelona, Barcelona, Spain.
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Kim HS, Cheon DY, Ha SO, Han SJ, Kim HS, Lee SH, Kim SG, Park S. Early changes in coagulation profiles and lactate levels in patients with septic shock undergoing extracorporeal membrane oxygenation. J Thorac Dis 2018; 10:1418-1430. [PMID: 29707291 DOI: 10.21037/jtd.2018.02.28] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Background To investigate the impact of coagulation profiles and lactate levels in patients with septic shock undergoing extracorporeal membrane oxygenation (ECMO). Methods A retrospective analysis of coagulation profiles, including disseminated intravascular coagulation (DIC) score, before and during 48 h of ECMO support [on day 0 (pre-ECMO), day 1, and day 2], was conducted in patients with septic shock undergoing ECMO. Results A total of 37 patients were included, and 15 (40.5%) patients survived. The initial DIC scores did not change in either the pre-ECMO overt-DIC (n=15) or non-overt-DIC (n=22) group after ECMO commencement. However, the DIC scores were significantly higher, at all three time-points, in non-survivors than in survivors. Additionally, the lactate levels improved considerably in the pre-ECMO non-overt-DIC group and in survivors during ECMO support, but not in the pre-ECMO overt DIC group or non-survivors. On a multivariate analysis, the pre-ECMO DIC score was significantly associated with hospital death [odds ratio (OR), 3.935; 95% confidence interval (CI), 1.170-13.230]. Receiver operating characteristic (ROC) curves revealed that the combination of pre-ECMO DIC score plus lactate level was the best predictor of hospital death (area under the curve, 0.879; 0.771-0.987); patients with combined scores >9.35 (the optimal cut-off) exhibited a three-fold higher mortality rate than did those with lower scores (81.8% vs. 26.7%, P=0.001). Conclusions During the early period of ECMO support, the coagulation profiles and lactate levels exhibited different trajectories in survivors and non-survivors. Furthermore, the pre-ECMO DIC score plus lactate level was the best predictor of hospital death.
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Affiliation(s)
- Hyoung Soo Kim
- Department of Cardiothoracic Surgery, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Dae Young Cheon
- Department of Internal Medicine, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sang Ook Ha
- Department of Emergency Medicine, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sang Jin Han
- Department of Cardiology, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Hyun-Sook Kim
- Department of Cardiology, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sun Hee Lee
- Department of Cardiothoracic Surgery, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sung Gyun Kim
- Department of Nephrology, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
| | - Sunghoon Park
- Department of Pulmonary, Allergy and Critical Care Medicine, Hallym University Sacred Heart Hospital, Anyang, South Korea
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Lee KW, Cho CW, Lee N, Choi GS, Cho YH, Kim JM, Kwon CHD, Joh JW. Extracorporeal membrane oxygenation support for refractory septic shock in liver transplantation recipients. Ann Surg Treat Res 2017; 93:152-158. [PMID: 28932731 PMCID: PMC5597539 DOI: 10.4174/astr.2017.93.3.152] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 03/21/2017] [Accepted: 04/18/2017] [Indexed: 12/13/2022] Open
Abstract
Purpose This study was designed to assess the outcome of the extracorporeal membrane oxygenation (ECMO) in liver transplantation (LT) recipients with refractory septic shock and predict the prognosis of those cases. Methods From February 2005 to October 2012, ECMO was used in 8 cases of refractory septic shock. Laboratory values including lactate and total bilirubin level just before starting ECMO were obtained and sepsis-related organ failure assessment (SOFA) score, acute physiology and chronic health evaluation (APACH) II score and simplified acute physiology score (SAPS) 3 were calculated. Subsequent peak serum lactate and total bilirubin level, and SOFA score after 24 hours of starting ECMO were measured. Results Comparisons were made between survivors and nonsurvivors. ECMO was weaned off successfully in 3 patients (37.5%) and 2 patients (25%) survived to hospital discharge. Clinical scores including SOFA, APACH II, and SAPS3 and laboratory results including lactate, total bilirubin and CRP were not significantly different between survivor and nonsurvivor groups. Lactate level and SOFA score tended to decrease after ECMO support in survivor group and total bilirubin and CRP level tended to increase in nonsurvivor group. Conclusion Our findings suggest that the implantation of ECMO might be considered in highly selected LT recipients with refractory septic shock.
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Affiliation(s)
- Kyo Won Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Chan Woo Cho
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Nuri Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jong Man Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Choon Hyuck David Kwon
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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9
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Cashen K, Hollis TK, Delius RE, Meert KL. Extracorporeal membrane oxygenation for pediatric cardiac failure: Review with a focus on unique subgroups. PROGRESS IN PEDIATRIC CARDIOLOGY 2016. [DOI: 10.1016/j.ppedcard.2016.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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10
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Kaestner M, Schranz D, Warnecke G, Apitz C, Hansmann G, Miera O. Pulmonary hypertension in the intensive care unit. Expert consensus statement on the diagnosis and treatment of paediatric pulmonary hypertension. The European Paediatric Pulmonary Vascular Disease Network, endorsed by ISHLT and DGPK. Heart 2016; 102 Suppl 2:ii57-66. [DOI: 10.1136/heartjnl-2015-307774] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2015] [Accepted: 06/29/2015] [Indexed: 02/04/2023] Open
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Steffen RJ, Miletic KG, Schraufnagel DP, Vargo PR, Fukamachi K, Stewart RD, Moazami N. Mechanical circulatory support in pediatrics. Expert Rev Med Devices 2016; 13:507-14. [DOI: 10.1586/17434440.2016.1162710] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Nair AB, Oishi P. Venovenous Extracorporeal Life Support in Single-Ventricle Patients with Acute Respiratory Distress Syndrome. Front Pediatr 2016; 4:66. [PMID: 27446889 PMCID: PMC4923132 DOI: 10.3389/fped.2016.00066] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2016] [Accepted: 06/01/2016] [Indexed: 02/05/2023] Open
Abstract
There is new and growing experience with venovenous extracorporeal life support (VV ECLS) for neonatal and pediatric patients with single-ventricle physiology and acute respiratory distress syndrome (ARDS). Outcomes in this population have been defined but could be improved; survival rates in single-ventricle patients on VV ECLS for respiratory failure are slightly higher than those in single-ventricle patients on venoarterial ECLS for cardiac failure (48 vs. 32-43%), but are lower than in patients with biventricular anatomy (58-74%). To that end, special consideration is necessary for patients with single-ventricle physiology who require VV ECLS for ARDS. Specifically, ARDS disrupts the balance between pulmonary and systemic blood flow through dynamic alterations in cardiopulmonary mechanics. This complexity impacts how to run the VV ECLS circuit and the transition back to conventional support. Furthermore, these patients have a complicated coagulation profile. Both venous and arterial thrombi carry marked risk in single-ventricle patients due to the vulnerability of the pulmonary, coronary, and cerebral circulations. Finally, single-ventricle palliation requires the preservation of low resistance across the pulmonary circulation, unobstructed venous return, and optimal cardiac performance including valve function. As such, the proper timing as well as the particular conduct of ECLS might differ between this population and patients without single-ventricle physiology. The goal of this review is to summarize the current state of knowledge of VV ECLS in the single-ventricle population in the context of these special considerations.
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Affiliation(s)
- Alison B Nair
- Department of Pediatrics, University of California San Francisco , San Francisco, CA , USA
| | - Peter Oishi
- Department of Pediatrics, University of California San Francisco, San Francisco, CA, USA; Cardiovascular Research Institute, University of California San Francisco, San Francisco, CA, USA
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Burke CR, McMullan DM. Extracorporeal Life Support for Pediatric Heart Failure. Front Pediatr 2016; 4:115. [PMID: 27812522 PMCID: PMC5071357 DOI: 10.3389/fped.2016.00115] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 10/05/2016] [Indexed: 11/15/2022] Open
Abstract
Extracorporeal life support (ECLS) represents an essential component in the treatment of the pediatric patient with refractory heart failure. Defined as the use of an extracorporeal system to provide cardiopulmonary support, ECLS provides hemodynamic support to facilitate end-organ recovery and can be used as a salvage therapy during acute cardiorespiratory failure. Support strategies employed in pediatric cardiac patients include bridge to recovery, bridge to therapy, and bridge to transplant. Advances in extracorporeal technology and refinements in patient selection have allowed wider application of this therapy in pediatric heart failure patients.
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Affiliation(s)
- Christopher R Burke
- Division of Cardiac Surgery, Seattle Children's Hospital , Seattle, WA , USA
| | - D Michael McMullan
- Division of Cardiac Surgery, Seattle Children's Hospital , Seattle, WA , USA
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Park TK, Yang JH, Jeon K, Choi SH, Choi JH, Gwon HC, Chung CR, Park CM, Cho YH, Sung K, Suh GY. Extracorporeal membrane oxygenation for refractory septic shock in adults. Eur J Cardiothorac Surg 2014; 47:e68-74. [DOI: 10.1093/ejcts/ezu462] [Citation(s) in RCA: 72] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Tattered and torn: the life of a RBC on the extracorporeal membrane oxygenation circuit. Crit Care Med 2014; 42:1314-5. [PMID: 24736354 DOI: 10.1097/ccm.0000000000000201] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Philip J, Burgman C, Bavare A, Akcan-Arikan A, Price JF, Adachi I, Shekerdemian LS. Nature of the underlying heart disease affects survival in pediatric patients undergoing extracorporeal cardiopulmonary resuscitation. J Thorac Cardiovasc Surg 2014; 148:2367-72. [PMID: 24787696 DOI: 10.1016/j.jtcvs.2014.03.023] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2014] [Revised: 02/24/2014] [Accepted: 03/13/2014] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To describe the use of extracorporeal membrane oxygenation (ECMO) in acute resuscitation after cardiac arrest in pediatric patients with heart disease, with reference to patient selection and predictors of outcome. METHODS A retrospective medical record review was performed of all patients aged ≤21 years with heart disease who had undergone ECMO for cardiopulmonary resuscitation (ECPR) at Texas Children's Hospital from January 2005 to December 2012. The most recent Pediatric Overall Performance Category score was determined from the patients' medical records. RESULTS During the study period, 62 episodes of ECPR occurred in 59 patients, with 27 (46%) surviving to hospital discharge and 25 (43%) alive at the most recent follow-up visit. The overall survival to discharge for patients with myocardial failure (myocarditis, cardiomyopathy, or after transplantation) and structural heart disease was similar (40% vs 50%, P=.6). No patient with restrictive cardiomyopathy survived; 1 patient (13%) in ECPR group after late cardiac graft failure survived to discharge. Survival to discharge was greater for patients who were intubated (70%) at cardiac arrest (P=.001). The presence of pre-existing acute kidney injury at cardiac arrest (62%) was associated with greater mortality (P=.059). A Pediatric Overall Performance Category score of ≤2 (indicating good neurologic performance) was present in 68% of the survivors; 7 patients (87%) with a score>2 had abnormal imaging findings (P=.01). CONCLUSIONS ECPR was associated with modest survival in pediatric patients with heart disease; however, this was associated in part with the underlying disease and pre-existing comorbidities, including the presence of acute kidney injury.
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Affiliation(s)
- Joseph Philip
- Congenital Heart Center, Shands Children's Hospital, University of Florida, Gainsville, Fla
| | - Cole Burgman
- Section of Critical Care and Congenital Heart Surgery, Department of Pediatrics, Baylor College of Medicine, Houston, Tex; Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Tex
| | - Aarti Bavare
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Tex; Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Tex
| | - Ayse Akcan-Arikan
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Tex; Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Tex
| | - Jack F Price
- Section of Critical Care Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, Tex; Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Tex; Section of Cardiology, Department of Pediatrics, Baylor College of Medicine, Houston, Tex
| | - Iki Adachi
- Department of Pediatrics, Baylor College of Medicine, Houston, Tex; Section of Congenital Heart Surgery, Department of Surgery, Baylor College of Medicine, Houston, Tex
| | - Lara S Shekerdemian
- Department of Pediatrics, Baylor College of Medicine, Houston, Tex; Section of Critical Care, Texas Section of Children's Hospital, Houston, Tex.
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Bastien O, Flamens C, Delannoy B. ECMO veinoartérielle au cours du choc cardiogénique et sa place dans le syndrome de détresse respiratoire aiguë : rationnel et objectifs cliniques. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-014-0871-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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