Extracorporeal life support in pediatric trauma: a systematic review

Outcomes of Extracorporeal Membrane Oxygenation in Acute Respiratory Distress Syndrome in Pediatric Trauma Patients

IMPORTANCE

Acute respiratory distress syndrome (ARDS) is associated with high mortality and morbidity. Extracorporeal membrane oxygenation (ECMO) is one of the interventions that have been in practice for ARDS for decades.

OBJECTIVES

The purpose of the study was to investigate the outcomes of ECMO in pediatric trauma patients who suffered from ARDS.

DESIGN

Observational cohort study.

SETTING AND PARTICIPANTS

The Trauma Quality Improvement Program database for years 2017 to 2019 and 2021 through 2022 was accessed for the study. All children younger than 18 years old who were admitted to the hospital after trauma and suffered from ARDS were included in the study. Other variables included in the study were patients' demographics, clinical characteristics, Injury Severity Score (ISS), Glasgow Coma Scale (GCS) score, comorbidities, and outcomes.

MAIN OUTCOMES AND MEASURES

ECMO is the exposure, and the outcomes are in-hospital mortality and hospital complications (acute kidney injury [AKI], pneumonia and deep vein thrombosis [DVT]).

RESULTS

Of 453 patients who qualified for the study, propensity score matching found 50 pairs of patients. There were no significant differences identified between the groups, ECMO+ vs. ECMO- on patients' age in years (16 yr; interquartile range [IQR], 13.25-17 yr vs. 16 yr [14.25-17 yr]), race (White; 62.0% vs. 66.0%), sex (male; 78% vs. 76%), ISS (23 [IQR, 9.25-34] vs. 22 [9.25-32]), and GCS (15 [IQR, 3-15] vs. 13.5 [3-15]), mechanism of injury; and comorbidities. There was no difference between the groups, ECMO+ vs. ECMO-, in-hospital mortality (10.0% vs. 20.0%; p = 0.302), hospital complications (AKI 12.0% vs. 2.0%; p = 0.131), pneumonia (10.0% vs. 20.0%; p = 0.182 > ), and DVT (16% vs. 6%; p = 0.228).

CONCLUSIONS AND RELEVANCE

No difference in mortality was observed in injured children who suffered from the ARDS and were placed on ECMO when compared with patients who were not placed on ECMO. Patients with trauma and ARDS who require ECMO have comparable outcomes to those who do not receive ECMO. A larger sample size study is needed to find the exact benefit of ECMO in this patients' cohort.

ECMO in trauma care: What you need to know

ABSTRACT

Over the past 10 years, extracorporeal membrane oxygenation (ECMO) use in trauma patients has increased significantly. This includes adult and pediatric trauma patients and even combat casualties. Most ECMO applications are in a venovenous (VV ECMO) configuration for acute hypoxemic respiratory failure or anatomic injuries that require pneumonectomy or extreme lung rest in a patient with insufficient respiratory reserve. In this narrative review, we summarize the most common indications for VV ECMO and other forms of ECMO support used in critically injured patients, underscore the importance of early ECMO consultation or regional referral, review the technical aspects of ECMO cannulation and management, and examine the expected outcomes for these patients. In addition, we evaluate the data where it exists to try to debunk some common myths surrounding ECMO management.

Outcome of Extracorporeal Cardiopulmonary Resuscitation in Pediatric Patients Without Congenital Cardiac Disease: Extracorporeal Life Support Organization Registry Study

OBJECTIVES

To describe the use of extracorporeal cardiopulmonary resuscitation (ECPR) in pediatric patients without congenital heart disease (CHD) and identify associations with in-hospital mortality, with a specific focus on initial arrest rhythm.

DESIGN

Retrospective cohort study using data from pediatric patients enrolled in Extracorporeal Life Support Organization (ELSO) registry between January 1, 2017, and December 31, 2019.

SETTING

International, multicenter.

PATIENTS

We included ECPR patients under 18 years old, and excluded those with CHD. Subgroup analysis of patients with initial arrest rhythm.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We identified 567 patients: neonates (12%), infants (27%), children between 1 and 5 years old (25%), and children over 5 years old (36%). The patient cohort included 51% males, 43% of White race, and 89% not obese. Most suffered respiratory disease (26%), followed by acquired cardiac disease (25%) and sepsis (12%). In-hospital mortality was 59%. We found that obesity (adjusted odds ratio [aOR], 2.28; 95% CI, 1.21-4.31) and traumatic injury (aOR, 6.94; 95% CI, 1.55-30.88) were associated with greater odds of in-hospital mortality. We also identified lower odds of death associated with White race (aOR, 0.64; 95% CI, 0.45-0.91), ventricular tachycardia (VT) as an initial arrest rhythm (aOR, 0.36; 95% CI, 0.16-0.78), return of spontaneous circulation before cannulation (aOR, 0.56; 95% CI, 0.35-0.9), and acquired cardiac disease (aOR, 0.43; 95% CI, 0.29-0.64). Respiratory disease was associated with greater odds of severe neurologic complications (aOR, 1.64; 95% CI, 1.06-2.54).

CONCLUSIONS

In children without CHD undergoing ECPR, we found greater odds of in-hospital mortality were associated with either obesity or trauma. The ELSO dataset also showed that other variables were associated with lesser odds of mortality, including VT as an initial arrest rhythm. Prospective studies are needed to elucidate the reasons for these survival differences.

Pediatric surgical interventions on ECMO

Extra Corporeal Membrane Oxygenation (ECMO) has historically been reserved for refractory pulmonary and cardiac support in children and adult. Operative intervention on ECMO was traditionally contraindicated due to hemorrhagic complications exacerbated by critical illness and anticoagulation needs. With advancements in ECMO circuitry and anticoagulation strategies operative procedures during ECMO have become feasible with minimal hemorrhagic risks. Here we review anticoagulation and operative intervention considerations in the pediatric population during ECMO cannulation. Pediatric surgical interventions currently described in the literature while on ECMO support include thoracotomy/thoracoscopy, tracheostomy, laparotomy, and injury related procedures i.e. wound debridement. A patient should not be precluded from a surgical intervention while on ECMO, if the surgery is indicated.

Case Report of a Successful Pediatric Central Venovenous Extracorporeal Life Support via Right Atrium-Pulmonary Artery Cannulation for Severe Chest Trauma and Hemorrhagic Shock

Hypoxemic arrests due to severe traumatic pulmonary injury may not respond to usual medical support. Extracorporeal life support (ECLS) can be life-saving; adequate flows are needed in this setting along with a careful choice of anticoagulation strategies to minimize bleeding. A 44 month old child, who presented with severe blunt chest trauma after being run over by a truck was resuscitated with active compressions and code medications seven times before arrival to the intensive care unit. Failure to adequately oxygenate led to an unconventional approach with cannulations of the right atrium (RA) and pulmonary artery (PA) via sternotomy. Anticoagulation regimen started after bleeding had slowed down with active transfusion of blood products and consisted of low-dose heparin and alprostadil infusions for the initial 48 hours. Heparin was adjusted per institutional guidelines thereafter. Physiologically veno-venous central approach enabled fast stabilization due to full oxygenation without recirculation. Additionally, the dual anticoagulation regimen was safe for circuit maintenance. The described method can be considered in small children with similar risks and conditions.

[Paediatric Life Support]

The European Resuscitation Council (ERC) Paediatric Life Support (PLS) guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR). This section provides guidelines on the management of critically ill or injured infants, children and adolescents before, during and after respiratory/cardiac arrest.

European Resuscitation Council Guidelines 2021: Paediatric Life Support

These European Resuscitation Council Paediatric Life Support (PLS) guidelines, are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the management of critically ill infants and children, before, during and after cardiac arrest.

Successful extracorporeal life support in a pediatric trauma patient following angioembolization of pelvic hemorrhage

Extracorporeal Life Support (ECLS) is rarely used in pediatric trauma patients due to bleeding risk, and the use of ECLS following angioembolization of traumatic hemorrhage has never been reported in a child. We report a case of a 10-year-old boy run over by a parade float resulting in severe thoracic, abdominal, and pelvic trauma, with hemorrhage from pelvic fractures requiring massive transfusion. Due to ongoing blood product requirements and contrast extravasation near the symphysis pubis, angioembolization of the internal iliac arteries was performed. Extreme hypoxemia persisted despite maximal ventilator support due to pulmonary contusions and aspiration pneumonitis. Six hours after angioembolization, venovenous ECLS was initiated. Following an initial heparin bolus, ECLS was run without anticoagulation for 12 h, but development of circuit clot required resumption of low-dose heparin. After four days, his respiratory status improved substantially and ECLS was discontinued. There were no hemorrhagic complications. The patient was discharged home in good health following inpatient rehabilitation. In this case, ECLS was successfully used in the treatment of post-traumatic respiratory failure 6 h following angioembolization of pelvic hemorrhage in a pediatric trauma patient. Further research is needed to determine the safest interval between hemorrhage control and ECLS in severely injured children.

Characteristics and outcomes of extracorporeal life support in pediatric trauma patients

BACKGROUND

Extracorporeal life support utilizing extracorporeal membrane oxygenation (ECMO) techniques has been used in the pediatric population for numerous indications, but its use in trauma has been understudied. We sought to examine the indications, characteristics, and outcomes of children placed on ECMO for trauma and hypothesized that outcomes would be equivalent to those of patients placed on ECMO for other indications.

METHODS

We performed a retrospective review of all pediatric trauma patients in the Extracorporeal Life Support Organization registry from 1989 to 2018. Patient characteristics, indications for ECMO, pre- and post-ECMO ventilator settings and blood chemistry, complications, and survival rates were examined. Categories were stratified by mode: venovenous (VV), veno-arterial (VA), or conversion. Data were analyzed using SPSS software, with significance considered at p value less than 0.05.

RESULTS

We identified 573 patients with a median age of 4.82 years. The majority of patients (62.3%) were male and on VA support (54.5%). Drowning (38.7%) was the most common mechanism, followed by burns (21.1%) and thoracic trauma (17.8%). Complication rates were high (81.9%), with the most frequent types being cardiovascular, mechanical, and hemorrhagic. Incidences of complications (overall and by type) were similar to those reported in other Extracorporeal Life Support Organization cohorts. Overall survival was 55.3% and was significantly higher (p = 0.00) for patients on VV (74.3%) compared with those on VA (41.7%), even when controlling for mechanism.

CONCLUSION

Survival and complication rates of pediatric trauma patients on ECMO are comparable to those reported for other indications. Trauma should not be considered a contraindication for ECMO.

LEVEL OF EVIDENCE

Therapeutic, level V.

Extracorporeal membrane oxygenation in the pediatric population - who should go on, and who should not

PURPOSE OF REVIEW

The role of extracorporeal membrane oxygenation (ECMO), a method of providing cardiorespiratory support in instances of cardiac or respiratory failure, in neonates and children continues to expand and evolve. This review details the current landscape of ECMO as it applies to neonates and children.

RECENT FINDINGS

Specifically, this review provides the most recent evidence for which patients should be considered for the various forms of ECMO including venovenous ECMO, venoarterial-ECMO, and extracorporeal cardiopulmonary resuscitation. Specific topics to be discussed include indications and contraindications for the different types of ECMO in neonates and children, anticoagulation strategies and ways to monitor end-organ function, outcomes specific to the different types and populations with a focus on meaningful survival to discharge and neurologic outcomes, and consideration of special populations such as low birth weight infants, traumatically injured patients, and children who received recent bone marrow transplants. This review also discusses still unanswered questions surrounding the most appropriate use of ECMO as its role and applications continue to evolve.

SUMMARY

With rapidly increasing utilization of ECMO, neonatologists and pediatricians should be aware of the most recent evidence guiding its indications, applications, and limitations.