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American Society of ExtraCorporeal Technology: Development of Standards and Guidelines for Pediatric and Congenital Perfusion Practice (2019). THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:319-326. [PMID: 33343035 DOI: 10.1182/ject-2000045] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 10/20/2020] [Indexed: 11/20/2022]
Abstract
The development of standards and guidelines by professional societies offers clinicians guidance toward providing evidence-based care. The ultimate goals of standards and guidelines are to standardize care and improve patient safety and outcomes while also minimizing risk. The American Society of ExtraCorporeal Technology (AmSECT) currently offers perfusionists several clinical resources, primarily the Standards and Guidelines for Perfusion Practice; however, no document exists specific to pediatric perfusion. Historically, the development of a pediatric-specific document has been limited by available scientific evidence because of smaller patient populations, sample sizes, and variable techniques among congenital perfusionists. In the current setting of evolving clinical practices and increasingly complex cardiac operations, a subcommittee of pediatric perfusionists developed the Standards and Guidelines for Pediatric and Congenital Perfusion Practice. The development process included a comprehensive literature review for supporting evidence to justify new recommendations or updates to the existing AmSECT Adult Standards and Guidelines document. Multiple revisions incorporating feedback from the community led to a finalized document accepted by the AmSECT member and made available electronically in May 2019. The Standards and Guidelines for Pediatric and Congenital Perfusion Practice is an essential tool for pediatric perfusionists, serves as the backbone for institutionally based protocols, promotes improved decision-making, and identifies opportunities for future research and collaboration with other disciplines. The purpose of this article is to summarize the process of development, the content, and recommended utilization of AmSECT's Standards and Guidelines for Pediatric and Congenital Perfusion Practice. AmSECT recommends adoption of the Standards and Guidelines for Pediatric and Congenital Perfusion Practice to reduce practice variation and enhance clinical safety.
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Oldeen ME, Angona RE, Hodge A, Klein T. American Society of ExtraCorporeal Technology: Development of Standards and Guidelines for Pediatric and Congenital Perfusion Practice (2019). World J Pediatr Congenit Heart Surg 2020; 12:84-92. [PMID: 33320047 DOI: 10.1177/2150135120956938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The development of standards and guidelines by professional societies offers clinicians guidance toward providing evidence-based care. The ultimate goals of standards and guidelines are to standardize care and improve patient safety and outcomes while also minimizing risk. The American Society of ExtraCorporeal Technology (AmSECT) currently offers perfusionists several clinical resources, primarily the Standards and Guidelines for Perfusion Practice; however, no document exists specific to pediatric perfusion. Historically, the development of a pediatric-specific document has been limited by available scientific evidence due to smaller patient populations, sample sizes, and variable techniques among congenital perfusionists. In the current setting of evolving clinical practices and increasingly complex cardiac operations, a subcommittee of pediatric perfusionists developed the Standards and Guidelines for Pediatric and Congenital Perfusion Practice. The development process included a comprehensive literature review for supporting evidence to justify new recommendations or updates to the existing AmSECT Adult Standards and Guidelines document. Multiple revisions incorporating feedback from the community led to a finalized document accepted by the AmSECT membership and made available electronically in May 2019. The Standards and Guidelines for Pediatric and Congenital Perfusion Practice is an essential tool for pediatric perfusionists and serves as the backbone for institutionally based protocols, promotes improved decision-making, and identifies opportunities for future research and collaboration with other disciplines. The purpose of this manuscript is to summarize the process of development, the content, and recommended utilization of AmSECT's Standards and Guidelines for Pediatric and Congenital Perfusion Practice.
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Affiliation(s)
- Molly Elisabeth Oldeen
- Division of Cardiovascular-Thoracic Surgery, 2429Ann & Robert H. Lurie Children's Hospital of Chicago, IL, USA
| | - Ronald E Angona
- 6923University of Rochester Medical Center, Strong Memorial Hospital, Rochester, NY, USA
| | - Ashley Hodge
- Cardiothoracic Surgery, The Heart Center, 2650Nationwide Children's Hospital, Columbus, OH, USA
| | - Tom Klein
- 2518Cincinnati Children's Hospital Medical Center, OH, USA
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The Organ-Protective Effect of Higher Partial Pressure of Arterial Carbon Dioxide in the Normal Range for Infant Patients Undergoing Ventricular Septal Defect Repair. Pediatr Cardiol 2020; 41:372-381. [PMID: 31844927 DOI: 10.1007/s00246-019-02269-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 12/07/2019] [Indexed: 10/25/2022]
Abstract
Hypercapnia has been reported to play an active role in protection against organ injury. The aim of this study was to determine whether a higher level of partial pressure of arterial carbon dioxide (PaCO2) within the normal range in pediatric patients undergoing cardiac surgery had a similar organ-protective effect. From May 2017 to May 2018, 83 consecutive infant patients undergoing ventricular septal defect (VSD) repair with cardiopulmonary bypass were retrospectively enrolled. We recorded the end-expiratory tidal partial pressure of carbon dioxide (Pet-CO2) as an indirect and continuous way to reflect the PaCO2. The patients were divided into a low PaCO2 group (LPG; 30 mmHg < Pet-CO2 < 40 mmHg) and a high PaCO2 group (HPG; 40 mmHg < Pet-CO2 < 50 mmHg). The regional cerebral oxygen saturation (rScO2), cerebral blood flow velocity (CBFV), and hemodynamics at five time points throughout the operation, and perioperative data were recorded and analyzed for the two groups. In total, 34 LPG and 49 HPG patients were included. Demographics and perioperative clinical data showed no significant difference between the groups. Compared with LPG, the HPG produced lower postoperative creatine kinase isoenzyme-MB (40.88 versus 50.34 ng/mL, P = 0.038). The postoperative C-reactive protein of HPG trended lower than in LPG (61.09 versus 73.4 mg/L, P = 0.056). The rScO2 and mean CBFV of HPG were significantly higher compared with LPG (P < 0.05) except at the end of cardiopulmonary bypass. Hemodynamic data showed no significant difference between the groups. As a convenient and safe approach, higher-normal PaCO2 could attenuate brain injury, heart injury, and inflammatory response in infant patients undergoing VSD repair.
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Hyperoxia and Hypocapnia During Pediatric Extracorporeal Membrane Oxygenation: Associations With Complications, Mortality, and Functional Status Among Survivors. Pediatr Crit Care Med 2018; 19:245-253. [PMID: 29319634 PMCID: PMC5834382 DOI: 10.1097/pcc.0000000000001439] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVES To determine the frequency of hyperoxia and hypocapnia during pediatric extracorporeal membrane oxygenation and their relationships to complications, mortality, and functional status among survivors. DESIGN Secondary analysis of data collected prospectively by the Collaborative Pediatric Critical Care Research Network. SETTING Eight Collaborative Pediatric Critical Care Research Network-affiliated hospitals. PATIENTS Age less than 19 years and treated with extracorporeal membrane oxygenation. INTERVENTIONS Hyperoxia was defined as highest PaO2 greater than 200 Torr (27 kPa) and hypocapnia as lowest PaCO2 less than 30 Torr (3.9 kPa) during the first 48 hours of extracorporeal membrane oxygenation. Functional status at hospital discharge was evaluated among survivors using the Functional Status Scale. MEASUREMENTS AND MAIN RESULTS Of 484 patients, 420 (86.7%) had venoarterial extracorporeal membrane oxygenation and 64 (13.2%) venovenous; 69 (14.2%) had extracorporeal membrane oxygenation initiated during cardiopulmonary resuscitation. Hyperoxia occurred in 331 (68.4%) and hypocapnia in 98 (20.2%). Hyperoxic patients had higher mortality than patients without hyperoxia (167 [50.5%] vs 48 [31.4%]; p < 0.001), but no difference in functional status among survivors. Hypocapnic patients were more likely to have a neurologic event (49 [50.0%] vs 143 (37.0%]; p = 0.021) or hepatic dysfunction (49 [50.0%] vs 121 [31.3%]; p < 0.001) than patients without hypocapnia, but no difference in mortality or functional status among survivors. On multivariable analysis, factors independently associated with increased mortality included highest PaO2 and highest blood lactate concentration in the first 48 hours of extracorporeal membrane oxygenation, congenital diaphragmatic hernia, and being a preterm neonate. Factors independently associated with lower mortality included meconium aspiration syndrome. CONCLUSIONS Hyperoxia is common during pediatric extracorporeal membrane oxygenation and associated with mortality. Hypocapnia appears to occur less often and although associated with complications, an association with mortality was not observed.
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Clair MP, Rambaud J, Flahault A, Guedj R, Guilbert J, Guellec I, Durandy A, Demoulin M, Jean S, Mitanchez D, Chalard F, Sileo C, Carbajal R, Renolleau S, Léger PL. Prognostic value of cerebral tissue oxygen saturation during neonatal extracorporeal membrane oxygenation. PLoS One 2017; 12:e0172991. [PMID: 28278259 PMCID: PMC5344369 DOI: 10.1371/journal.pone.0172991] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 01/31/2017] [Indexed: 12/02/2022] Open
Abstract
Objectives Extracorporeal membrane oxygenation support is indicated in severe and refractory respiratory or circulatory failures. Neurological complications are typically represented by acute ischemic or hemorrhagic lesions, which induce higher morbidity and mortality. The primary goal of this study was to assess the prognostic value of cerebral tissue oxygen saturation (StcO2) on mortality in neonates and young infants treated with ECMO. A secondary objective was to evaluate the association between StcO2 and the occurrence of cerebral lesions. Study design This was a prospective study in infants < 3 months of age admitted to a pediatric intensive care unit and requiring ECMO support. Measurements The assessment of cerebral perfusion was made by continuous StcO2 monitoring using near-infrared spectroscopy (NIRS) sensors placed on the two temporo-parietal regions. Neurological lesions were identified by MRI or transfontanellar echography. Results Thirty-four infants <3 months of age were included in the study over a period of 18 months. The ECMO duration was 10±7 days. The survival rate was 50% (17/34 patients), and the proportion of brain injuries was 20% (7/34 patients). The mean StcO2 during ECMO in the non-survivors was reduced in both hemispheres (p = 0.0008 right, p = 0.03 left) compared to the survivors. StcO2 was also reduced in deceased or brain-injured patients compared to the survivors without brain injury (p = 0.002). Conclusion StcO2 appears to be a strong prognostic factor of survival and of the presence of cerebral lesions in young infants during ECMO.
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Affiliation(s)
- Marie-Philippine Clair
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Jérôme Rambaud
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Adrien Flahault
- Laboratory of Central Neuropeptides in the Regulation of Body Fluid Homeostasis and Cardiovascular Functions, Center for Interdisciplinary Research in Biology (CIRB), INSERM, U1050, Paris, France
- CNRS, UMR 7241, Paris, France
| | - Romain Guedj
- Department of Emergency medicine, Trousseau Hospital, AP-HP, Paris, France
| | - Julia Guilbert
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Isabelle Guellec
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Amélie Durandy
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Maryne Demoulin
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | - Sandrine Jean
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
| | | | - François Chalard
- Department of Pediatric Radiology, Trousseau Hospital, AP-HP, Paris, France
| | - Chiara Sileo
- Department of Pediatric Radiology, Trousseau Hospital, AP-HP, Paris, France
| | - Ricardo Carbajal
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
- Department of Emergency medicine, Trousseau Hospital, AP-HP, Paris, France
- UPMC Pierre et Marie Curie University, Paris VI, France
| | - Sylvain Renolleau
- Department of Pediatric intensive care unit, Necker Hospital, AP-HP, Paris, France
| | - Pierre-Louis Léger
- Department of Neonatal and Pediatric intensive care unit, Trousseau Hospital, AP-HP, Paris, France
- * E-mail:
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Muellenbach RM, Kilgenstein C, Kranke P, Küstermann J, Kredel M, Roewer N, Ernestus RI, Westermaier T. Effects of venovenous extracorporeal membrane oxygenation on cerebral oxygenation in hypercapnic ARDS. Perfusion 2013; 29:139-41. [PMID: 23887087 DOI: 10.1177/0267659113497073] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is increasingly used in ARDS patients with hypoxemia and/or severe hypercapnia refractory to conventional treatment strategies. However, it is associated with severe intracranial complications, e.g. ischemic or hemorrhagic stroke. The arterial carbon dioxide partial pressure (PaCO2) is one of the main determinants influencing cerebral blood flow and oxygenation. Since CO2 removal is highly effective during ECMO, reduction of CO2 may lead to alterations in cerebral perfusion. We report on the variations of cerebral oxygenation during the initiation period of ECMO treatment in a patient with hypercapnic ARDS, which may partly explain the findings of ischemic and/or hemorrhagic complications in conjunction with ECMO.
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