1
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Young T, Ezzat B, Nichols N, Aydin S, Pastuszko P, Morgenstern PF. Managing medically refractory elevated intracranial pressure in a pediatric patient on ECMO: illustrative case. Childs Nerv Syst 2024:10.1007/s00381-024-06549-8. [PMID: 39046474 DOI: 10.1007/s00381-024-06549-8] [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: 04/12/2024] [Accepted: 07/17/2024] [Indexed: 07/25/2024]
Abstract
PURPOSE We demonstrate the complexities of managing pediatric patients on extracorporeal membrane oxygenation (ECMO) therapy requiring neurosurgery, focusing on systemic anticoagulation, cardiac function, and medically refractory intracranial pressure (ICP). METHODS A 3.5-year-old female with Tetralogy of Fallot developed severe ischemic cerebral edema following post-operative cardiac arrest and required ECMO. This case, along with four additional cases of children requiring neurosurgery while on ECMO, was examined. RESULTS Emergency neurosurgical intervention in the primary case led to significant improvement, highlighting the delicate balance between managing ECMO-induced anticoagulation and urgent neurosurgical needs. The additional cases had variable outcomes, emphasizing the challenges of caring for these critically ill patients. CONCLUSION Successful management of children requiring ECMO support and neurosurgical intervention requires thoughtful multidisciplinary care. This report illustrates some of the nuances in such decision-making, and demonstrates one potential path to a good outcome.
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Affiliation(s)
- Tirone Young
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Bahie Ezzat
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Noah Nichols
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA
| | - Scott Aydin
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter Pastuszko
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Department of Thoracic Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Peter F Morgenstern
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, 10029, USA.
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
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2
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Schiller O, Pula G, Shostak E, Manor-Shulman O, Frenkel G, Amir G, Yacobovich J, Nellis ME, Dagan O. Patient-tailored platelet transfusion practices for children supported by extracorporeal membrane oxygenation. Vox Sang 2024; 119:326-334. [PMID: 38175143 DOI: 10.1111/vox.13583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND AND OBJECTIVES Extracorporeal membrane oxygenation (ECMO) serves as cardiopulmonary therapy in critically ill patients with respiratory/heart failure and often necessitates multiple blood product transfusions. The administration of platelet transfusions during ECMO is triggered by the presence or risk of significant bleeding. Most paediatric ECMO programmes follow guidelines that recommend a platelet transfusion threshold of 80-100 × 109/L. To reduce exposure to platelets, we developed a practice to dynamically lower the threshold to ~20 × 109/L. We describe our experience with patient-tailored platelet thresholds and related bleeding outcomes. MATERIALS AND METHODS We retrospectively evaluated our platelet transfusion policy, bleeding complications and patient outcome in 229 ECMO-supported paediatric patients in our unit. RESULTS We found that more than 97.4% of patients had a platelet count <100 × 109/L at some point during their ECMO course. Platelets were transfused only on 28.5% of ECMO days; and 19.2% of patients never required a platelet transfusion. The median lowest platelet count in children who had bleeding events was 25 × 109/L as compared to 33 × 109/L in children who did not bleed (p < 0.001). Our patients received fewer platelet transfusions and did not require more red blood cell transfusions, nor did they experience more haemorrhagic complications. CONCLUSION We have shown that a restrictive, 'patient-tailored' rather than 'goal-directed' platelet transfusion policy is feasible and safe, which can greatly reduce the use of platelet products. Although there was a difference in the lowest platelet counts in children who bled versus those who did not, the median counts were much lower than current recommendations.
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Affiliation(s)
- Ofer Schiller
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Giulia Pula
- Children's Heart Centre, Division of Cardiology, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Eran Shostak
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Orit Manor-Shulman
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Georgy Frenkel
- Division of Pediatric Cardiothoracic Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Gabriel Amir
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Division of Pediatric Cardiothoracic Surgery, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Joanne Yacobovich
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- Pediatric Hematology-Oncology Center, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
| | - Marianne E Nellis
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, NY Presbyterian Hospital - Weill Cornell Medicine, New York, New York, USA
| | - Ovadia Dagan
- Pediatric Cardiac Intensive Care Unit, Schneider Children's Medical Center of Israel, Petach Tikva, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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Shah N, Mathur S, Shanmugham P, Li X, Thiagarajan RR, Natarajan S, Raman L. Neurologic Statistical Prognostication and Risk Assessment for Kids on Extracorporeal Membrane Oxygenation-Neuro SPARK. ASAIO J 2024; 70:305-312. [PMID: 38557687 DOI: 10.1097/mat.0000000000002106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/04/2024] Open
Abstract
This study presents Neuro-SPARK, the first scoring system developed to assess the risk of neurologic injury in pediatric and neonatal patients on extracorporeal membrane oxygenation (ECMO). Using the extracorporeal life support organization (ELSO) registry, we applied robust machine learning methodologies and clinical expertise to a 10 years dataset. We produced separate models for veno-venous (V-V ECMO) and veno-arterial (V-A ECMO) configurations due to their different risk factors and prevalence of neurologic injury. Our models identified 14 predictor variables for V-V ECMO and 20 for V-A ECMO, which demonstrated moderate accuracy in predicting neurologic injury as defined by the area under the receiver operating characteristic (AUROC) (V-V = 0.63, V-A = 0.64) and good calibration as measured by the Brier score (V-V = 0.1, V-A = 0.15). Furthermore, our post-hoc analysis identified high- and low-risk groups that may aid clinicians in targeted neuromonitoring and guide future research on ECMO-associated neurologic injury. Despite the inherent limitations, Neuro-SPARK lays the foundation for a risk-assessment tool for neurologic injury in ECMO patients, with potential implications for improved patient outcomes.
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Affiliation(s)
- Neel Shah
- From the Department of Pediatrics, Washington University in St. Louis, St. Louis, Missouri
| | - Saurabh Mathur
- Department of Computer Science, University of Texas at Dallas, Richardson, Texas
| | | | - Xilong Li
- Department of Population and Data Science, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Ravi R Thiagarajan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
| | - Sriraam Natarajan
- Department of Computer Science, University of Texas at Dallas, Richardson, Texas
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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4
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Ivanov Y, Buratto E, Konstantinov IE, Clifford M, Brizard CP, Horton S. Clinical assessment can be lifesaving: Salvage of catastrophic cerebral ischemia by conversion to central extracorporeal membrane oxygenation. Perfusion 2024; 39:612-614. [PMID: 36751733 DOI: 10.1177/02676591221148045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Peripheral veno-artertial extracorporeal membrane oxygenation (VA-ECMO) is commonly used in the paediatric population for intractable respiratory and cardiac failure. One of the devastating complications of VA-ECMO is severe brain damage due to ischemia or haemorrhage. We describe a case of peripheral cervical VA-ECMO complicated by evolving right cerebral ischemia which was rescued with rapid conversion from peripheral to central VA-ECMO support. Notably, the patient had a complete circle of Willis. Following conversion, we observed complete resolution of neurological symptoms with full functional recovery.
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Affiliation(s)
- Yaroslav Ivanov
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, VIC, Australia
| | - Edward Buratto
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
- Heart Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Igor E Konstantinov
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
- Heart Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Melbourne Children's Centre for Cardiovascular Genomics and Regenerative Medicine, Melbourne, VIC, Australia
| | - Michel Clifford
- Department of Intensive Care Medicine, Royal Children's Hospital, Parkville, VIC, Australia
| | - Christian P Brizard
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
- Heart Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
| | - Stephen Horton
- Department of Cardiac Surgery, Royal Children's Hospital Melbourne, Parkville, VIC, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, Australia
- Heart Research Group, Murdoch Children's Research Institute, Parkville, VIC, Australia
- Department of Perfusion, Royal Children's Hospital, Melbourne, VIC, Australia
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5
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Duarte CM, Lopes MI, Abecasis F. Transfusion policy in pediatric extracorporeal membrane oxygenation patients: Less could be more. Perfusion 2024; 39:96-105. [PMID: 35634987 DOI: 10.1177/02676591221105610] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2023]
Abstract
OBJECTIVE To evaluate a restrictive transfusion policy of red blood cells (RBC) and platelets in pediatric patients submitted to extracorporeal membrane oxygenation (ECMO). METHODS Retrospective descriptive study of pediatric patients supported with ECMO, from January 2010 to December 2019. Hemoglobin, platelet, lactate and mixed venous oxygen saturation (SvO2) values of each patient while on ECMO, were collected. Transfusion efficiency and tissue oxygenation were statistically evaluated comparing pre-transfusion hemoglobin, lactate and SvO2 with post-transfusion values. Ranges of hemoglobin and platelets were established, and the number of transfusions registered. The bleeding complications and outcome were documented. RESULTS Of a total of 1016 hemoglobin values, the mean value before transfusion was 8.6 g/dl. Hemoglobin and SvO2 increased significantly post-transfusion. Red blood cell transfusion varied with hemoglobin values: when hemoglobin value was less than 7 g/dl, 89% (41/46) were transfused but just 23% (181/794) when greater or equal to 7 g/dl. In the presence of active bleeding, the frequency of RBC transfusion increased from 32% to 62%, with hemoglobin between 7 g/dl and 8 g/dl.The mean value for platelet transfusion was 32 x 109/L. Thirty-eight (43%) platelet values between 20 x 109/L and 30x109/L, and 31 (40%) between 30 x 109/L and 40 x 109/L led to platelet transfusion; between 40 x 109/L and 50 x 109/L, only 7 (9%) prompted platelet transfusion.Comparing the 2010-2015 to 2016-2019 periods there was a decrease in RBC and platelet transfusion threshold with similar survival (p = .528). Survival to discharge was 68%. CONCLUSIONS Using a restrictive RBC and platelet transfusion policy was safe and allowed a good outcome in this case series. The presence of active bleeding was an important decision factor when hemoglobin was above 7 g/dl and platelets were above 30 x 109/L.
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Affiliation(s)
- Catarina Marques Duarte
- Pediatric Department Lisbon Academic Medical Center, Hospital Santa Maria (CHULN), Lisbon, Portugal
| | - Maria Inȇs Lopes
- Lisbon Academic Medical Center, Hospital Santa Maria (CHULN), Lisbon, Portugal
| | - Francisco Abecasis
- Pediatric Intensive Care Unit, Pediatric Department, Lead of Pediatric Interhospital Transport System and Neonatal and Pediatric ECMO program, Hospital Santa Maria (CHULN), Portugal
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6
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Dantes G, Keene S. Transfusion in Neonatal Extracorporeal Membrane Oxygenation: A Best Practice Review. Clin Perinatol 2023; 50:839-852. [PMID: 37866851 DOI: 10.1016/j.clp.2023.07.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2023]
Abstract
Extracorporeal Membrane Oxygenation (ECMO) is an important tool for managing critically ill neonates. Bleeding and thrombotic complications are common and significant. An understanding of ECMO physiology, its interactions with the unique neonatal hemostatic pathways, and appreciation for the distinctive risks and benefits of neonatal transfusion as it applies to ECMO are required. Currently, there is variability regarding transfusion practices, related to changing norms and a lack of high-quality literature and trials. This review provides an analysis of the neonatal ECMO transfusion literature and summarizes available best practice guidelines.
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Affiliation(s)
- Goeto Dantes
- Department of Surgery, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA; Emory University School of Medicine, Emory University, Atlanta, GA, USA.
| | - Sarah Keene
- Emory University School of Medicine, Emory University, Atlanta, GA, USA; Department of Neonatology, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA; Emory + Children's Pediatric Institute, Atlanta, GA, USA
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Salha A, Chowdhury T, Singh S, Luyt J, Harky A. Optimizing Outcomes in Extracorporeal Membrane Oxygenation Postcardiotomy in Pediatric Population. J Pediatr Intensive Care 2023; 12:245-255. [PMID: 37970139 PMCID: PMC10631840 DOI: 10.1055/s-0041-1731682] [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: 03/16/2021] [Accepted: 05/29/2021] [Indexed: 10/20/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) is a rapidly emerging advanced life support technique used in cardiorespiratory failure refractory to other treatments. There has been an influx in the number of studies relating to ECMO in recent years, as the technique becomes more popular. However, there are still significant gaps in the literature including complications and their impacts and methods to predict their development. This review evaluates the available literature on the complications of ECMO postcardiotomy in the pediatric population. Areas explored include renal, cardiovascular, hematological, infection, neurological, and hepatic complications. Incidence, risk factors and potential predictors, and scoring systems for the development of these complications have been evaluated.
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Affiliation(s)
- Ahmad Salha
- Department of Medicine, St George's Hospital Medical School, London, United Kingdom
| | - Tasnim Chowdhury
- Department of Medicine, St George's Hospital Medical School, London, United Kingdom
| | - Saloni Singh
- School of Medicine, University of Central Lancashire, Preston, United Kingdom
| | - Jessica Luyt
- Department of Paediatric Intensive Care, Alder Hey Children's Hospital, Liverpool, United Kingdom
| | - Amer Harky
- Department of Cardiac Surgery, Alder Hey Children Hospital, Liverpool, United Kingdom
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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8
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Felling RJ, Kamerkar A, Friedman ML, Said AS, LaRovere KL, Bell MJ, Bembea MM. Neuromonitoring During ECMO Support in Children. Neurocrit Care 2023; 39:701-713. [PMID: 36720837 DOI: 10.1007/s12028-023-01675-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 01/10/2023] [Indexed: 02/02/2023]
Abstract
Extracorporeal membrane oxygenation is a potentially lifesaving intervention for children with severe cardiac or respiratory failure. It is used with increasing frequency and in increasingly more complex and severe diseases. Neurological injuries are important causes of morbidity and mortality in children treated with extracorporeal membrane oxygenation and include ischemic stroke, intracranial hemorrhage, hypoxic-ischemic injury, and seizures. In this review, we discuss the epidemiology and pathophysiology of neurological injury in patients supported with extracorporeal membrane oxygenation, and we review the current state of knowledge for available modalities of monitoring neurological function in these children. These include structural imaging with computed tomography and ultrasound, cerebral blood flow monitoring with near-infrared spectroscopy and transcranial Doppler ultrasound, and physiological monitoring with electroencephalography and plasma biomarkers. We highlight areas of need and emerging advances that will improve our understanding of neurological injury related to extracorporeal membrane oxygenation and help to reduce the burden of neurological sequelae in these children.
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Affiliation(s)
- Ryan J Felling
- Department of Neurology, Johns Hopkins University School of Medicine, 200 N. Wolfe Street, Suite 2158, Baltimore, MD, USA.
| | - Asavari Kamerkar
- Department of Anesthesia Critical Care Medicine, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Matthew L Friedman
- Division of Pediatric Critical Care, Indiana School of Medicine, Indianapolis, IN, USA
| | - Ahmed S Said
- Division of Pediatric Critical Care, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital and Harvard Medical School, Boston, MA, USA
| | - Michael J Bell
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
| | - Melania M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Pandiyan P, Cvetkovic M, Antonini MV, Shappley RKH, Karmakar SA, Raman L. Clinical Guidelines for Routine Neuromonitoring in Neonatal and Pediatric Patients Supported on Extracorporeal Membrane Oxygenation. ASAIO J 2023; 69:895-900. [PMID: 37603797 DOI: 10.1097/mat.0000000000001896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/23/2023] Open
Abstract
DISCLAIMER These guidelines for routine neuromonitoring in neonatal and pediatric patients supported on extracorporeal membrane oxygenation (ECMO) are intended for educational use to build the knowledge of physicians and other health professionals in assessing the conditions and managing the treatment of patients undergoing extracorporeal life support (ECLS)/ECMO and describe what are believed to be useful and safe practice for ECLS and ECMO but these are not necessarily consensus recommendations. The aim of clinical guidelines was to help clinicians to make informed decisions about their patients. However, adherence to a guideline does not guarantee a successful outcome. Healthcare professionals must make their own treatment decisions about care on a case-by-case basis, after consultation with their patients, using their clinical judgment, knowledge, and expertise. These guidelines do not take the place of physicians' and other health professionals' judgment in diagnosing and treatment of patients. These guidelines are not intended to and should not be interpreted as setting a standard of care or being deemed inclusive of all proper methods of care nor exclusive of other methods of care directed at obtaining the same results. The ultimate judgment must be made by the physician and other health professionals and the patient considering all the circumstances presented by the individual patient, and the known variability and biologic behavior of the clinical condition. These guidelines reflect the data at the time the guidelines were prepared; the results of subsequent studies or other information may cause revisions to the recommendations in these guidelines to be prudent to reflect new data, but ELSO is under no obligation to provide updates. In no event will ELSO be liable for any decision made or action taken in reliance upon the information provided through these guidelines.
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Affiliation(s)
- Poornima Pandiyan
- From the Department of Pediatrics, Division of Medical Critical Care, Boston Children's Hospital, Tufts University School of Medicine, Boston, Massachusetts
| | - Mirjana Cvetkovic
- Cardiac Critical Care Division, Heart and Lung Directorate, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marta Velia Antonini
- Anesthesia and Intensive Care Unit, Bufalini Hospital - AUSL della Romagna, Cesena, Italy
- Department of Biomedical, Metabolic and Neural Science, University of Modena and Reggio Emilia, Modena, Italy
| | - Rebekah K H Shappley
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Swati A Karmakar
- Department of Pediatrics, Baylor College of Medicine, Neurology and Developmental Neuroscience Section, Texas Children's Hospital, Houston, Texas
| | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, Texas
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Callier K, Dantes G, Johnson K, Linden AF. Pediatric ECLS Neurologic Management and Outcomes. Semin Pediatr Surg 2023; 32:151331. [PMID: 37944407 DOI: 10.1016/j.sempedsurg.2023.151331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Neurologic complications associated with extracorporeal life support (ECLS), including seizures, ischemia/infarction, and intracranial hemorrhage significantly increase morbidity and mortality in pediatric and neonatal patients. Prompt recognition of adverse neurologic events may provide a window to intervene with neuroprotective measures. Many neuromonitoring modalities are available with varying benefits and limitations. Several pre-ECLS and ECLS-related factors have been associated with an increased risk for neurologic complications. These may be patient- or circuit-related and include modifiable and non-modifiable factors. ECLS survivors are at risk for long-term neurological sequelae affecting neurodevelopmental outcomes. Possible long-term outcomes range from normal development to severe impairment. Patients should undergo a neurological evaluation prior to discharge, and neurodevelopmental assessments should be included in each patient's structured, multidisciplinary follow-up. Safe pediatric and neonatal ECLS management requires a thorough understanding of neurological complications, neuromonitoring techniques and limitations, considerations to minimize risk, and an awareness of possible long-term ramifications. With a focus on ECLS for respiratory failure, this manuscript provides a review of these topics and summarizes best practice guidelines from international organizations and expert consensus.
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Affiliation(s)
- Kylie Callier
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Goeto Dantes
- Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA.
| | - Kevin Johnson
- Department of Pediatric Surgery, Vanderbilt University School of Medicine, Nashville, TN
| | - Allison F Linden
- Department of Surgery, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, GA, USA
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11
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Sanford EL, Akorede R, Miller I, Morriss MC, Nandy K, Raman L, Busch DR. Association Between Disrupted Cerebral Autoregulation and Radiographic Neurologic Injury for Children on Extracorporeal Membrane Oxygenation: A Prospective Pilot Study. ASAIO J 2023; 69:e315-e321. [PMID: 37172001 DOI: 10.1097/mat.0000000000001970] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
Validation of a real-time monitoring device to evaluate the risk or occurrence of neurologic injury while on extracorporeal membrane oxygenation (ECMO) may aid clinicians in prevention and treatment. Therefore, we performed a pilot prospective cohort study of children under 18 years old on ECMO to analyze the association between cerebral blood pressure autoregulation as measured by diffuse correlation spectroscopy (DCS) and radiographic neurologic injury. DCS measurements of regional cerebral blood flow were collected on enrolled patients and correlated with mean arterial blood pressure to determine the cerebral autoregulation metric termed DCSx. The primary outcome of interest was radiographic neurologic injury on eligible computed tomography (CT) or magnetic resonance imaging (MRI) scored by a blinded pediatric neuroradiologist utilizing a previously validated scale. Higher DCSx scores, which indicate disruption of cerebral autoregulation, were associated with higher radiographic neurologic injury score (slope, 11.0; 95% confidence interval [CI], 0.29-22). Patients with clinically significant neurologic injury scores of 10 or more had higher median DCSx measures than patients with lower neurologic injury scores (0.48 vs . 0.13; p = 0.01). Our study indicates that obtaining noninvasive DCS measures for children on ECMO is feasible and disruption of cerebral autoregulation determined from DCS is associated with higher radiographic neurologic injury score.
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Affiliation(s)
- Ethan L Sanford
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Rufai Akorede
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Isabel Miller
- UT Southwestern Medical Center Medical School, Dallas, Texas
| | - Michael Craig Morriss
- Department of Radiology, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - Karabi Nandy
- Peter O'Donnell Jr. School of Public Health, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Lakshmi Raman
- Division of Pediatric Critical Care Medicine, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
| | - David R Busch
- From the Department of Anesthesiology and Pain Management, UT Southwestern Medical Center/Children's Medical Center, Dallas, Texas
- Department of Neurology, UT Southwestern Medical Center, Dallas, Texas
- Department of Biomedical Engineering, UT Southwestern Medical Center, Dallas, Texas
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12
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Lin G, Li Y, Zhuang Y, Fan Q, Luo Y, Zeng H. Seizures in children undergoing extracorporeal membrane oxygenation: a systematic review and meta-analysis. Pediatr Res 2023; 93:755-762. [PMID: 35906308 PMCID: PMC9336161 DOI: 10.1038/s41390-022-02187-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To investigate the incidence of seizures and short-term mortality associated with seizures in children undergoing extracorporeal membrane oxygenation (ECMO). METHODS PubMed, Embase, and Web of Science were searched from inception to September 2021. Study quality was assessed using the Newcastle-Ottawa Scale. Random effects meta-analysis was conducted. RESULTS Fourteen studies met the inclusion criteria for quantitative meta-analysis. The cumulative estimate of seizure incidence was 15% (95% CI: 12-17%). Studies using electroencephalography reported a higher incidence of seizures compared with those using electro-clinical criteria (19% vs. 9%, P = 0.034). Furthermore, 75% of seizures were subclinical. Children receiving extracorporeal cardiopulmonary resuscitation (ECPR) exhibited a higher incidence of seizures compared to children with respiratory and cardiac indications. Seizure incidence was higher in patients undergoing venoarterial (VA) ECMO compared with venovenous (VV) ECMO. The pooled odds ratio of mortality was 2.58 (95% CI: 2.25-2.95) in those developed seizures. CONCLUSION The incidence of seizures in children requiring ECMO was 15% and majority of seizures were subclinical. The incidence of seizures was higher in patients receiving ECPR than in those with respiratory and cardiac indications. Seizures were more frequent in patients undergoing VA ECMO than VV ECMO. Seizures were associated with increased short-term mortality. IMPACT The incidence of seizures in children undergoing extracorporeal membrane oxygenation (ECMO) was ~15% and majority of the seizures were subclinical. Seizures were associated with increased short-term mortality. Risk factors for seizures were extracorporeal cardiopulmonary resuscitation and venoarterial ECMO. Electroencephalography (EEG) monitoring is recommended in children undergoing ECMO and further studies on the optimal protocol for EEG monitoring are necessary.
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Affiliation(s)
- Guisen Lin
- Department of Radiology, Shenzhen Children's Hospital, Shenzhen, China
| | - Yaowen Li
- Department of Radiology, Shenzhen Children's Hospital, Shenzhen, China
| | - Yijiang Zhuang
- Department of Radiology, Shenzhen Children's Hospital, Shenzhen, China
| | - Qimeng Fan
- Department of Pediatric Intensive Care Unit, Shenzhen Children's Hospital, Shenzhen, China
| | - Yi Luo
- Department of Radiology, Shenzhen Children's Hospital, Shenzhen, China
- Shantou University Medical College, Shantou, China
| | - Hongwu Zeng
- Department of Radiology, Shenzhen Children's Hospital, Shenzhen, China.
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Duangpakdee P, Sakkarat S, Sangkhathat S. Survival Outcome in Critically Ill Patients Receiving Extracorporeal Membrane Oxygenation Support: Early Experience from a University Hospital in Thailand. Surg J (N Y) 2023; 9:e44-e51. [PMID: 36793996 PMCID: PMC9925292 DOI: 10.1055/s-0043-1761444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 11/30/2022] [Indexed: 02/16/2023] Open
Abstract
Objective Extracorporeal membrane oxygenation (ECMO) is a relatively new technology used for life support in patients with cardiopulmonary failure from various causes. The objective of this study is to review the first 5-year experience in adopting this technology in a teaching hospital in southern Thailand. Methods The data of ECMO-supported patients in Songklanagarind Hospital, from the years 2014 to 2018, were retrospectively reviewed. Data sources were from electronic medical records and the database of the perfusion service. Parameters in focus included prior conditions and indications of ECMO, type of ECMO and cannulation method, complications during and after the treatment, and discharge statuses. Results A total of 83 patients received ECMO life support during the 5-year period and the number of cases per year increased. The proportion of venovenous: venoarterial ECMO in our institute was 49:34 cases and there were three cases who used ECMO as a part of cardiopulmonary resuscitation. Moreover, there were 57 cases who used ECMO for cardiac failure and 26 cases were for respiratory causes, while premature withdrawal was decided in 26 cases (31.3%). Overall survival from ECMO was 35/83 cases (42.2%) and survival to discharge was 32/83 (38.6%). During therapy, ECMO could restore serum pH to the normal range in all cases. Furthermore, those who used ECMO for respiratory failure had significantly higher survival probability (57.7%) when compared to the cardiac counterpart (29.8%, p -value = 0.03). Patients with younger ages also had significantly better survival outcomes. The most common complications were cardiac (75 cases, 85.5%), followed by renal (45 cases, 54.2%), and hematologic systems (38 cases, 45.8%). In those who survived to discharge, average ECMO duration was 9.7 days. Conclusion Extracorporeal life support is a technology that bridges the patients with cardiopulmonary failure to their recovery or definitive surgery. Despite the high complication rate, survival can be expected, especially in respiratory failure cases and relatively young patients.
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Affiliation(s)
- Pongsanae Duangpakdee
- Department of Surgery, Division of Cardio-Thoracic Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand,Address for correspondence Pongsanae Duangpakdee, MD Department of Surgery, Division of Cardio-Thoracic Surgery, Faculty of Medicine, Prince of Songkla UniversityHat Yai, Songkhla 90110Thailand
| | - Sasitorn Sakkarat
- Department of Surgery, Division of Cardio-Thoracic Surgery, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
| | - Surasak Sangkhathat
- Department of Surgery and Translational Medicine Research Center, Faculty of Medicine, Prince of Songkla University, Hat Yai, Songkhla, Thailand
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14
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Del Puppo M, Meister L, Médale M, Allary C, Nicollas R, Moreddu E. Heliox simulations for initial management of congenital laryngotracheal stenosis. Pediatr Pulmonol 2023; 58:230-238. [PMID: 36208011 PMCID: PMC10092700 DOI: 10.1002/ppul.26189] [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: 03/24/2022] [Revised: 09/22/2022] [Accepted: 09/26/2022] [Indexed: 01/11/2023]
Abstract
OBJECTIVES Congenital laryngotracheal stenosis is rare, potentially severe, and difficult to manage. Heliox is a medical gas effective in obstructive airway pathologies, given its physical properties. This study aims to model the interest of Heliox in reducing the respiratory work in congenital laryngotracheal stenosis, using numerical fluid flow simulations, before considering its clinical use. DESIGN This is a retrospective study, performing Computational Fluid Dynamics numerical simulations of the resistances to airflow and three types of Heliox, on 3D reconstructions from CT scans of children presenting with laryngotracheal stenosis. PATIENTS Infants and children who were managed in the Pediatric ENT department of a tertiary-care center and underwent CT scanning for laryngotracheal stenosis between 2008 and 2018 were included. RESULTS Fourteen models of congenital laryngotracheal stenosis were performed in children aged from 16 days to 5 years, and one model of the normal trachea in a 5-year-old child. Tightest stenosis obtained the highest airway resistances, ranging from 40 to 10 kPa/L/s (up to 800 times higher than in the normal case). Heliox enabled a decrease in pressure drops and airway resistances in all stenosis cases, correlated to increasing Helium concentration. CONCLUSIONS Heliox appears to reduce pressure drops and airway resistances in 3D models of laryngotracheal stenosis. It may represent a supportive treatment for laryngotracheal stenosis, while waiting for specialized care, thanks to the reduction of respiratory work.
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Affiliation(s)
- Marine Del Puppo
- Department of Pediatric Otolaryngology Head and Neck Surgery, La Timone Children's Hospital, AP-HM, Aix Marseille Université, Marseille, France.,Energetic Mechanics Department, Institut Universitaire des Systèmes Thermiques et Industriels, UMR 7343 CNRS, Aix Marseille Université, Marseille, France
| | - Lionel Meister
- Energetic Mechanics Department, Institut Universitaire des Systèmes Thermiques et Industriels, UMR 7343 CNRS, Aix Marseille Université, Marseille, France
| | - Marc Médale
- Energetic Mechanics Department, Institut Universitaire des Systèmes Thermiques et Industriels, UMR 7343 CNRS, Aix Marseille Université, Marseille, France
| | - Chloé Allary
- Department of Pediatric Anesthesia and Intensive Care, La Timone Children's Hospital, AP-HM, Aix Marseille Université, Marseille, France
| | - Richard Nicollas
- Department of Pediatric Otolaryngology Head and Neck Surgery, La Timone Children's Hospital, AP-HM, Aix Marseille Université, Marseille, France.,Energetic Mechanics Department, Institut Universitaire des Systèmes Thermiques et Industriels, UMR 7343 CNRS, Aix Marseille Université, Marseille, France
| | - Eric Moreddu
- Department of Pediatric Otolaryngology Head and Neck Surgery, La Timone Children's Hospital, AP-HM, Aix Marseille Université, Marseille, France.,Energetic Mechanics Department, Institut Universitaire des Systèmes Thermiques et Industriels, UMR 7343 CNRS, Aix Marseille Université, Marseille, France
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15
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Beshish AG, Rodriguez Z, Hani Farhat M, Newman JW, Jahadi O, Baginski M, Bradley J, Rao N, Figueroa J, Viamonte H, Chanani NK, Owens GE, Barbaro R, Yarlagadda V, Ryan KR. Functional Status Change Among Infants, Children, and Adolescents Following Extracorporeal Life Support: a Multicenter Report. ASAIO J 2023; 69:114-121. [PMID: 35435861 DOI: 10.1097/mat.0000000000001711] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
In our retrospective multicenter study of patients 0 to 18 years of age who survived extracorporeal life support (ECLS) between January 2010 and December 2018, we sought to characterize the functional status scale (FSS) of ECLS survivors, determine the change in FSS from admission to discharge, and examine risk factors associated with development of new morbidity and unfavorable outcome. During the study period, there were 1,325 ECLS runs, 746 (56%) survived to hospital discharge. Pediatric patients accounted for 56%. Most common ECLS indication was respiratory failure (47%). ECLS support was nearly evenly split between veno-arterial and veno-venous (51% vs . 49%). Median duration of ECLS in survivors was 5.5 days. Forty percent of survivors had new morbidity, and 16% had an unfavorable outcome. In a logistic regression, African American patients (OR 1.68, p = 0.01), longer duration of ECLS (OR 1.002, p = 0.004), mechanical (OR 1.79, p = 0.002), and renal (OR 1.64, p = 0.015) complications had higher odds of new morbidity. Other races (Pacific Islanders, and Native Americans) (OR 2.89, p = 0.013), longer duration of ECLS (OR 1.002, p = 0.002), and mechanical complications (OR 1.67, p = 0.026) had higher odds of unfavorable outcomes. In conclusion, in our multi-center 9-year ECLS experience, 56% survived, 40% developed new morbidity, and 84% had favorable outcome. Future studies with larger populations could help identify modifiable risk factors that could help guide clinicians in this fragile patient population.
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Affiliation(s)
- Asaad G Beshish
- From the Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Division of Cardiology, Atlanta, GA
| | - Zahidee Rodriguez
- From the Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Division of Cardiology, Atlanta, GA
| | - Mohamed Hani Farhat
- C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Department of Pediatrics, Division of Pediatric Critical Care, Ann Arbor, MI
| | - Jordan W Newman
- Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Division of Pediatric Critical Care, Atlanta, GA
| | - Ozzie Jahadi
- Division of Pediatric Cardiovascular Surgery, Lucile Packard Children's Hospital Stanford, Palo Alto
| | | | | | - Nikita Rao
- Division of Pediatric Cardiothoracic Surgery, Children's Healthcare of Atlanta, Atlanta, GA
| | - Janet Figueroa
- Biostatistician and Data Analyst, Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Atlanta, GA
| | - Heather Viamonte
- From the Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Division of Cardiology, Atlanta, GA
| | - Nikhil K Chanani
- From the Children's Healthcare of Atlanta, Emory University School of Medicine, Department of Pediatrics, Division of Cardiology, Atlanta, GA
| | - Gabe E Owens
- C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Department of Pediatrics, Division of Pediatric Cardiology, Ann Arbor, MI
| | - Ryan Barbaro
- C.S. Mott Children's Hospital, University of Michigan, Michigan Medicine, Department of Pediatrics, Division of Pediatric Critical Care, Ann Arbor, MI
| | - Vamsi Yarlagadda
- Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Department of Pediatrics, Division of Cardiology, Palo Alto, CA
| | - Kathleen R Ryan
- Lucile Packard Children's Hospital Stanford, Stanford University Medical Center, Department of Pediatrics, Division of Cardiology, Palo Alto, CA
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Tierradentro-Garcia LO, Stern JA, Dennis R, Hwang M. Utility of Cerebral Microvascular Imaging in Infants Undergoing ECMO. CHILDREN (BASEL, SWITZERLAND) 2022; 9:1827. [PMID: 36553271 PMCID: PMC9776869 DOI: 10.3390/children9121827] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 11/18/2022] [Accepted: 11/20/2022] [Indexed: 11/29/2022]
Abstract
PURPOSE Infants who require extracorporeal membrane oxygenation (ECMO) therapy have an increased risk of neurological complications and mortality. Microvascular imaging (MVI) is an advanced Doppler technique that allows high-resolution visualization of microvasculature in the brain. We describe the feasibility and utility of MVI for the evaluation of cerebral microvascular perfusion in patients undergoing ECMO. METHODS We retrospectively analyzed brain MVI scans of neonates undergoing ECMO. Two pediatric radiologists qualitatively assessed MVI scans to determine the presence or absence of tortuosity, symmetry, heterogeneity, engorgement, and hypoperfusion of the basal ganglia-thalamus (BGT) region, as well as the presence or absence of white matter vascular engorgement and increased peri-gyral flow in the cortex. We tested the association between the presence of the aforementioned brain MVI features and clinical outcomes. RESULTS We included 30 patients, 14 of which were male (46.7%). The time of ECMO duration was 11.8 ± 6.9 days. The most prevalent microvascular finding in BGT was lenticulostriate vessel tortuosity (26/30, 86.7%), and the most common microvascular finding in the cortex was increased peri-gyral flow (10/24, 41.7%). Cortical white matter vascular engorgement was significantly associated with the presence of any poor outcome as defined by death, seizure, and/or cerebrovascular events on magnetic resonance imaging (p = 0.03). CONCLUSION MVI is a feasible modality to evaluate cerebral perfusion in infants undergoing ECMO. Additionally, evidence of white matter vascular engorgement after ECMO cannulation could serve as a predictor of poor outcomes in this population.
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Affiliation(s)
| | - Joseph A. Stern
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
| | - Rebecca Dennis
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - Misun Hwang
- Department of Pediatric Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA 19104, USA
- Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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17
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Association Between Early Change in Arterial Carbon Dioxide Tension and Outcomes in Neonates Treated by Extracorporeal Membrane Oxygenation. ASAIO J 2022; 69:411-416. [PMID: 36730940 PMCID: PMC10044589 DOI: 10.1097/mat.0000000000001838] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
The primary objective was to investigate the association between partial pressure of carbon dioxide (PaCO2) change after extracorporeal membrane oxygenation (ECMO) initiation and neurologic outcome in neonates treated for respiratory failure. A retrospective analysis of the Extracorporeal Life Support Organization (ELSO) database including newborns supported by ECMO for respiratory indication during 2015-2020. The closest Pre-ECMO (Pre-ECMO PaCO2) and at 24 hours after ECMO initiation (H24 PaCO2) PaCO2 values allowed to calculate the relative change in PaCO2 (Rel Δ PaCO2 = [H24 PaCO2 - Pre-ECMO PaCO2]/Pre-ECMO PaCO2). The primary outcome was the onset of any acute neurologic event (ANE), defined as cerebral bleeding, ischemic stroke, clinical or electrical seizure, or brain death during ECMO. We included 3,583 newborns (median age 1 day [interquartile range {IQR}, 1-3], median weight 3.2 kg [IQR, 2.8-3.6]) from 198 ELSO centers. The median Rel Δ PaCO2 value was -29.9% [IQR, -46.2 to -8.5]. Six hundred nine (17%) of them had ANE (405 cerebral bleedings, 111 ischemic strokes, 225 seizures, and 6 brain deaths). Patients with a decrease of PaCO2 > 50% were more likely to develop ANE than others (odds ratio [OR] 1.78, 95% confidence interval [CI], 1.31-2.42, p < 0.001). This was still observed after adjustment for all clinically relevant confounding factors (adjusted OR 1.94, 95% CI, 1.29-2.92, p = 0.001). A significant decrease in PaCO2 after ECMO start is associated with ANE among neonates requiring ECMO for respiratory failure. Cautious PaCO2 decrease should be considered after start of ECMO therapy.
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18
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Stroke in pediatric ECMO patients: analysis of the National Inpatient Sample (NIS) database. Pediatr Res 2022; 92:754-761. [PMID: 35505077 DOI: 10.1038/s41390-022-02088-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 03/30/2022] [Accepted: 04/07/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND The rates, outcomes, and long-term trends of stroke complicating the use of extracorporeal membrane oxygenation (ECMO) have been inconsistently reported. We compared the outcomes of pediatric ECMO patients with and without stroke and described the frequency trends between 2000 and 2017. METHODS Using the National Inpatient Sample (NIS) database, pediatric patients (age ≤18 years) who received ECMO were identified using ICD-9&10 codes. Binary, regression, and trend analyses were performed to compare patients with and without stroke. RESULTS A total of 114,477,997 records were reviewed. Overall, 28,695 (0.025%) ECMO patients were identified of which 2982 (10.4%) had stroke, which were further classified as hemorrhagic (n = 1464), ischemic (n = 1280), or combined (n = 238). Mortality was higher in the hemorrhagic and combined groups compared to patients with ischemic stroke and patients without stroke. Length of stay (LOS) was significantly longer in stroke vs. no-stroke patients. Hypertension and septicemia were more encountered in the hemorrhagic group, whereas the combined group demonstrated higher frequency of cardiac arrest and seizures. CONCLUSIONS Over the years, there is an apparent increase in the diagnosis of stroke. All types of stroke in ECMO patients are associated with increased LOS, although mortality is increased in hemorrhagic and combined stroke only. IMPACT Stroke is a commonly seen complication in pediatric patients supported by ECMO. Understanding the trends will help in identifying modifiable risk factors that predict poor outcomes in this patient population.
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19
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Azapagasi E, Kendirli T, Tunçer GO, Perk O, Isikhan SY, Tıras ST, Eyileten Z, Ince E, Uysalel A, Akar AR. Early Neurologic Complications and Long-term Neurologic Outcomes of Extracorporeal Membrane Oxygenation Performed in Children. KLINISCHE PADIATRIE 2022; 234:96-104. [PMID: 35189653 DOI: 10.1055/a-1749-6096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND We aimed at evaluating acute neurologic complications (ANC) and clinical outcome at a 2-year follow-up in children after extracorporeal membrane oxygenation (ECMO). METHODS We conducted a single-center, retrospective review of our patient cohort aged between 1 month and 18 years at the time of ECMO support (between June 2014 to January 2017). Outcome analysis included ANC and their clinical consequences.The Pediatric Overall Performance Category (POPC) and Pediatric Cerebral Performance Category (PCPC) were used for neurologic assessment performed at discharge from the hospital and at 2nd year follow-up. RESULTS There were 35 children who required ECMO. The median ECMO time was 9 days (range 2-32 days). Decannulation from ECMO was achieved in 68.6% of patients, and overall, 42.8% survived (15 patients), The incidence of ANC in the surviving patients was 40% (6 children). ANC were intracranial hemorrhage, seizures, cerebral infarction, which occurred in one, two and three of the 15 surviving patients respectively (6.6, 13.3 and 20%). A higher rate of organ failure was related to death (p=0.043), whereas duration on ECMO was a risk factor for the development of ANC (p<0.05). At hospital discharge, the 14 patients evaluated had normal development or -mild disability in 73.2%, and at the 2-year follow-up, 93.4% had these scores. CONCLUSION Children who receive ECMO have a risk to develop ANC, which was related to the length of ECMO treatment, while survival was related to less organ failure, Long-term neurological outcome was good in our patient cohort.
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Affiliation(s)
- Ebru Azapagasi
- Pediatric Intensive Care, Dr Sami Ulus Gynecology Obstetrics and Child Health and Diseases Training and Research Hospital, Ankara, Turkey
| | - Tanıl Kendirli
- Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Gokcen Oz Tunçer
- Pediatric Neurology , Ankara University Faculty of Medicine, Ankara, Turkey
| | - Oktay Perk
- Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| | | | - Serap Teber Tıras
- Pediatric Neurology , Ankara University Faculty of Medicine, Ankara, Turkey
| | - Zeynep Eyileten
- Pediatric Cardiac Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Erdal Ince
- Pediatric Intensive Care, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Adnan Uysalel
- Pediatric Cardiac Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
| | - Ahmet Rüçhan Akar
- Cardiovascular Surgery, Ankara University Faculty of Medicine, Ankara, Turkey
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20
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Jenks CL, Landry LM, Garrison CF, Campbell JG, Weeks MF, Tramel SW, Knudson JD. Pediatric Extracorporeal Membrane Oxygenation Anticoagulation Protocol Associated with a Decrease in Complications. ASAIO J 2022; 68:275-280. [PMID: 33883505 DOI: 10.1097/mat.0000000000001438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Extracorporeal membrane oxygenation (ECMO) in pediatrics has rapidly progressed in recent years; however, there continues to be considerable variation in anticoagulation practices. In 2016, we implemented a standardized anticoagulation protocol in effort to reduce clotting and bleeding complications. A single-center retrospective analysis of pediatric patients requiring ECMO between 2014 and 2018 was performed. One hundred one ECMO cases in 94 pediatric patients met eligibility criteria (preprotocol = 64 cases; postprotocol = 37 cases). Demographics, ECMO parameters, complications, laboratories, and blood product requirements were analyzed for differences between the two groups. There was a significant decrease in the incidence of hematologic (p < 0.022), neurologic (p < 0.001), and renal complications (p < 0.001) in the postprotocol era. Incidence of bleeding, cardiac/pulmonary complications, and circuit changes were similar between the groups. The postprotocol group required fewer transfusions of red blood cells and cryoprecipitate. Additionally, platelet counts and fibrinogen levels were maintained higher in the postprotocol era. In conclusion, implementation of a standardized anticoagulation protocol was associated with improved anticoagulation parameters and a decrease in hematologic and neurologic complications, coagulopathy, renal injury, and blood product administration. We attribute these findings to transitioning to anti-Xa as a measure of heparinization and maintaining higher platelet counts.
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Affiliation(s)
- Christopher L Jenks
- From the Department of Pediatrics, Division of Pediatric Critical Care, University of Mississippi Medical Center, Jackson, Mississippi
| | - Lily M Landry
- Department of Pediatrics, Division of Pediatric Cardiology, University of Mississippi Medical Center, Jackson, Mississippi
| | - Carrie F Garrison
- Department of Pediatrics, Division of Pediatric Critical Care, Studer Family Children's Hospital at Sacred Heart, Pensacola, Florida
| | - Joshua G Campbell
- School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Mary F Weeks
- School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Sarah W Tramel
- School of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Jarrod D Knudson
- From the Department of Pediatrics, Division of Pediatric Critical Care, University of Mississippi Medical Center, Jackson, Mississippi
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21
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Cui Y, Zhang Y, Dou J, Shi J, Zhao Z, Zhang Z, Chen Y, Cheng C, Zhu D, Quan X, Zhu X, Huang W. Venovenous vs. Venoarterial Extracorporeal Membrane Oxygenation in Infection-Associated Severe Pediatric Acute Respiratory Distress Syndrome: A Prospective Multicenter Cohort Study. Front Pediatr 2022; 10:832776. [PMID: 35391748 PMCID: PMC8982932 DOI: 10.3389/fped.2022.832776] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Accepted: 02/21/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been increasingly used as rescue therapy for severe pediatric acute respiratory distress syndrome (PARDS) over the past decade. However, a contemporary comparison of venovenous (VV) and venoarterial (VA) ECMO in PARDS has yet to be well described. Therefore, the objective of our study was to assess the difference between VV and VA ECMO in efficacy and safety for infection-associated severe PARDS patients. METHODS This prospective multicenter cohort study included patients with infection-associated severe PARDS who received VV or VA ECMO in pediatric intensive care units (PICUs) of eight university hospitals in China between December 2018 to June 2021. The primary outcome was in-hospital mortality. Secondary outcomes included ECMO weaning rate, duration of ECMO and mechanical ventilation (MV), ECMO-related complications, and hospitalization costs. RESULTS A total of 94 patients with 26 (27.66%) VV ECMO and 68 (72.34%) VA ECMO were enrolled. Compared to the VA ECMO patients, VV ECMO patients displayed a significantly lower in-hospital mortality (50 vs. 26.92%, p = 0.044) and proportion of neurologic complications, shorter duration of ECMO and MV, but the rate of successfully weaned from ECMO, bleeding, bloodstream infection complications and pump failure were similar. By contrast, oxygenator failure was more frequent in patients receiving VV ECMO. No significant intergroup difference was observed for the hospitalization costs. CONCLUSION These positive findings showed the conferred survival advantage and safety of VV ECMO compared with VA ECMO, suggesting that VV ECMO may be an effective initial treatment for patients with infection-associated severe PARDS.
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Affiliation(s)
- Yun Cui
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Yucai Zhang
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Jiaying Dou
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Jingyi Shi
- Department of Critical Care Medicine, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.,Institute of Pediatric Critical Care, Shanghai Jiao Tong University, Shanghai, China
| | - Zhe Zhao
- Pediatric Intensive Care Unit, Senior Department of Pediatrics, The Seventh Medical Center of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhen Zhang
- Pediatric Intensive Care Unit, First Hospital of Jilin University, Changchun, China
| | - Yingfu Chen
- Critical Care Medicine, Children's Hospital Affiliated to Chongqing Medical University, Chongqing, China
| | - Chao Cheng
- Pediatric Intensive Care Unit, Shengjing Hospital Affiliated to China Medical University, Shenyang, China
| | - Desheng Zhu
- Department of Critical Care Medicine, Hunan Children's Hospital, Changsha, China
| | - Xueli Quan
- Surgical Intensive Care Unit of Henan Children's Hospital, Children's Hospital Affiliated to Zhengzhou University, Zhengzhou, China
| | - Xuemei Zhu
- Critical Care Medicine, Children's Hospital Affiliated to Fudan University, Shanghai, China
| | - Wenyan Huang
- Department of Nephrology and Rheumatology, Shanghai Children's Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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22
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Ko JY, Lee MR, Ha EH, Kim A. Peripheral neuropathy after extra-corporeal membrane oxygenation therapy in children: A case report. Medicine (Baltimore) 2021; 100:e27735. [PMID: 34766582 PMCID: PMC10545386 DOI: 10.1097/md.0000000000027735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 10/14/2021] [Accepted: 10/22/2021] [Indexed: 11/25/2022] Open
Abstract
RATIONALE In recent years, the use of extracorporeal membrane oxygenation (ECMO) treatment for pediatric patients with cardiorespiratory failure has increased, with emphasis being given to the prevention of complications in ECMO-treated patients. Several studies have reported ECMO-related central nervous system complications, such as intracranial hemorrhage, cerebral infarction, and seizure. However, few cases of peripheral nerve injury have been reported in ECMO-treated adults; there have also been no reported cases of peripheral nerve injury in the pediatric population. PATIENT CONCERNS Two pediatric patients aged 16 and 6 experienced motor weakness in the extremities after the insertion of ECMO equipment. DIAGNOSES They were diagnosed with peripheral nerve injuries through an electrodiagnostic study that showed femoral/sciatic neuropathies and brachial plexopathy. Arteriography and doppler sonography was performed to find the cause of peripheral nerve injury, and this may be the results of vascular compromise and compressive injuries, respectively. INTERVENTIONS Surgical embolectomy was performed to remove thrombus in one patient. Two patients received orthosis, and physical therapy and occupational therapy were performed to prevent contracture and improve strength and functional use. OUTCOMES Two pediatric patients showed a gradual improvement in motor power and function. LESSONS Through this case report, we present rare ECMO-related complications and emphasize the importance of early diagnosis and monitoring of peripheral nerve injury in ECMO-treated children.
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Affiliation(s)
- Jun Young Ko
- Department of Rehabilitation Medicine, Myongji Hospital, 14-55 Hwasu-ro, Deokyang-gu, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Mi rim Lee
- Department of Rehabilitation Medicine, Myongji Hospital, 14-55 Hwasu-ro, Deokyang-gu, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Eun-Hye Ha
- Division of Pulmonary and Critical Care Medicine, Myongji Hospital, 14-55 Hwasu-ro, Deokyang-gu, Goyang-si, Gyeonggi-do, Republic of Korea
| | - Aram Kim
- Department of Rehabilitation Medicine, Myongji Hospital, 14-55 Hwasu-ro, Deokyang-gu, Goyang-si, Gyeonggi-do, Republic of Korea
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Mudery J, Starr JP, Batra A, Kelly RB. Timely Use of Venous-Arterial ECMO to Treat Congenital Pediatric Junctional Ectopic Tachycardia: A Case Report. J Investig Med High Impact Case Rep 2021; 9:23247096211034045. [PMID: 34293947 PMCID: PMC8312163 DOI: 10.1177/23247096211034045] [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] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Supraventricular tachycardia is the most common tachyarrhythmia in pediatrics. Although postoperative junctional ectopic tachycardia (JET) is a known complication of congenital heart surgery that is typically transient, congenital JET is rare and requires aggressive treatment to maintain hemodynamic stability. We describe the case of a 3-month-old, previously healthy female who presented with heart failure and cardiogenic shock secondary to congenital JET for whom extracorporeal membrane oxygenation (ECMO) provided time for selection of effective therapy. Adenosine, cardioversion, and transesophageal pacing were unsuccessful, and her echocardiogram demonstrated bilateral atrial dilation and severe left ventricular systolic dysfunction. Approximately 8 hours after presentation, venous-arterial ECMO was commenced allowing for successful treatment with amiodarone. Her electrocardiogram demonstrated atrioventricular dissociation consistent with JET. She was successfully decannulated from ECMO after 6 days. Her discharge echocardiogram showed normal ventricular function, and she had no significant ECMO sequelae. This case demonstrates the value of early ECMO initiation for cardiovascular support in pediatric patients with a life-threatening arrhythmia and in cardiogenic shock. ECMO support can allow for full diagnostic and therapeutic decisions to effectively reverse the consequences of uncontrolled arrhythmias unrelated to surgical complications.
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Affiliation(s)
| | | | - Anjan Batra
- University of California, Irvine, CA, USA.,Children's Hospital of Orange County, Orange, CA, USA
| | - Robert B Kelly
- University of California, Irvine, CA, USA.,Children's Hospital of Orange County, Orange, CA, USA
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24
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Hassumani DO, Shan M, Mastropietro CW, Wing SE, Friedman ML. Seizures in Children with Cardiac Disease on Extracorporeal Membrane Oxygenation. Neurocrit Care 2021; 36:157-163. [PMID: 34268643 DOI: 10.1007/s12028-021-01276-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 05/11/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Children supported with extracorporeal membrane oxygenation (ECMO) have been shown to be at risk for developing seizures. However, previous studies have consisted of heterogeneous patient populations. We aimed to describe the rate of seizures in pediatric patients receiving ECMO for cardiac indications and to identify risk factors for the occurrence of this complication. METHODS This is a retrospective cohort study of consecutive pediatric patients on ECMO for congenital or acquired cardiac disease between 2014 and 2018 at a tertiary care pediatric hospital. RESULTS We reviewed 110 children, of whom 104 (95%) received continuous electroencephalogram for at least 48 h after ECMO initiation. Seizures were observed in 20 (18%) children. Seizures were subclinical only in 13 (65%) patients, and 8 (40%) developed status epilepticus. The median time from ECMO initiation to first seizure was 34 h (25%, 75%: 19, 44). Children with seizures were more likely to have suffered pre-ECMO cardiac arrest (odds ratio 5.7, 95% confidence interval 2.0-16.1, p < 0.001), require extracorporeal cardiopulmonary resuscitation (odds ratio 5.2, 95% confidence interval 1.9-14.7, p < 0.001), and have been cannulated via the cervical vessels (p = 0.029). Children with seizures also had lower pH nadir prior to ECMO (p = 0.015) and had higher peak lactate prior to ECMO (p = 0.002). Patients with seizures had significantly a longer median intensive care unit length of stay, (43 versus 32 days, p = 0.02), had a significantly worse pediatric cerebral performance score (2 versus 1, p = 0.03), and tended to have worse survival to hospital discharge (50% versus 71%, p = 0.069). CONCLUSIONS Seizures in pediatric patients on ECMO for cardiac indications are common, occurring in nearly one in five patients. Seizures are frequently subclinical only and often progress to status epilepticus. Continuous electroencephalogram is therefore warranted for this patient population, especially in the setting of cardiac arrest, extracorporeal cardiopulmonary resuscitation, or severe metabolic acidosis.
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Affiliation(s)
- Daniel O Hassumani
- Section of Pediatric Critical Care, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
| | - Mu Shan
- Department of Biostatistics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, Indianapolis, IN, USA
| | - Christopher W Mastropietro
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, Phase 2, Room 4900, Indianapolis, IN, 46202-5225, USA
| | - Sarah E Wing
- Division of Pediatric Neurology, Department of Neurology, Indiana University School of Medicine and Riley Hospital for Children At Indiana University Health, Indianapolis, IN, USA
| | - Matthew L Friedman
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Hospital for Children at Indiana University Health, 705 Riley Hospital Drive, Phase 2, Room 4900, Indianapolis, IN, 46202-5225, USA.
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25
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Douraghi-Zadeh D, Logaraj A, Lazoura O, Downey K, Gill S, Finney SJ, Padley S. Extracorporeal membrane oxygenation (ECMO): Radiographic appearances, complications and imaging artefacts for radiologists. J Med Imaging Radiat Oncol 2021; 65:888-895. [PMID: 34219399 DOI: 10.1111/1754-9485.13280] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2021] [Accepted: 06/15/2021] [Indexed: 11/26/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a form of cardiopulmonary support primarily used in cardiothoracic and intensive care unit (ICU) settings. The purpose of this review is to familiarise radiologists with the imaging features of ECMO devices, their associated complications and appropriate imaging protocols for contrast-enhanced CT imaging of ECMO patients. This paper will provide a brief introduction to ECMO and the imaging modalities utilised in ECMO patients, followed by a description of the types of ECMO available and cannula positioning. Indications and contraindications for ECMO will be outlined followed by a description of the complications associated with ECMO, which radiologists should recognise. Finally, the imaging protocol and interpretation of contrast-enhanced CT imaging in ECMO patients will be discussed. In the current clinical climate with millions of COVID-19 cases around the world and tens of thousands of critically ill patients, many requiring cardiopulmonary support in intensive care units, the use of ECMO in adults has increased, and thus so has the volume of imaging. Radiologists need to be familiar with the types of ECMO available, the correct positioning of the catheters depending on the type of ECMO being utilised, and the associated complications and imaging artefacts.
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Affiliation(s)
| | - Anthony Logaraj
- Department of Radiology, Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Olga Lazoura
- Department of Radiology, Royal Free London NHS Trust, London, UK
| | | | - Simon Gill
- Department of Radiology, Frimley Health NHS Trust, Surrey, UK
| | - Simon J Finney
- Department of Intensive Care, Barts Health NHS Trust, London, UK
| | - Simon Padley
- Department of Radiology, Royal Brompton & Harefield NHS Trust, London, UK
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26
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Heinsar S, Raman S, Suen JY, Cho HJ, Fraser JF. The use of extracorporeal membrane oxygenation in children with acute fulminant myocarditis. Clin Exp Pediatr 2021; 64:188-195. [PMID: 32777915 PMCID: PMC8103038 DOI: 10.3345/cep.2020.00836] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 07/02/2020] [Indexed: 12/28/2022] Open
Abstract
Acute fulminant myocarditis (AFM) occurs as an inflammatory response to an initial myocardial insult. Its rapid and deadly progression calls for prompt diagnosis with aggressive treatment measures. The demonstration of its excellent recovery potential has led to increasing use of mechanical circulatory support, especially extracorporeal membrane oxygenation (ECMO). Arrhythmias, organ failure, elevated cardiac biomarkers, and decreased ventricular function at presentation predict requirement for ECMO. In these patients, ECMO should be considered earlier as the clinical course of AFM can be unpredictable and can lead to rapid haemodynamic collapse. Key uncertainties that clinicians face when managing children with AFM such as timing of initiation of ECMO and left ventricular decompression need further investigation.
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Affiliation(s)
- Silver Heinsar
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Sainath Raman
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Paediatric Critical Care Research Group, Child Health Research Centre, The University of Queensland, Queensland, Australia.,Paediatric Intensive Care Unit, Queensland Children's Hospital, South Brisbane, Australia
| | - Jacky Y Suen
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
| | - Hwa Jin Cho
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia.,Department of Pediatrics, Chonnam National University Children's Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - John F Fraser
- Critical Care Research Group, Faculty of Medicine, University of Queensland and The Prince Charles Hospital, Brisbane, Australia
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27
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Noninvasive neurocritical care monitoring for neonates on extracorporeal membrane oxygenation: where do we stand? J Perinatol 2021; 41:830-835. [PMID: 32753710 DOI: 10.1038/s41372-020-0762-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Revised: 07/06/2020] [Accepted: 07/22/2020] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine practice variation in the utilization of neuromonitoring modalities in neonatal extracorporeal membrane oxygenation (ECMO) patients across Level IV neonatal intensive care units (NICUs). STUDY DESIGN Cross-sectional survey design using electronic surveys sent to site sponsors of a multicenter collaborative of 34 Level IV NICUs of the Children's Hospitals Neonatal Consortium (CHNC) from June to August 2018. RESULTS We had 22 survey respondents from CHNC ECMO centers. Twenty-seven percent of respondents routinely monitored for seizures using electroencephalogram. Cerebral near infrared spectroscopy was used by 50%. Head ultrasound was performed by 95% but the frequency, duration, and type of views varied. Post ECMO screening brain MRI prior to hospital discharge was routinely performed by 77% of respondents. A majority of centers (95%) performed neurodevelopmental follow-up after hospital discharge. CONCLUSIONS There is variation in neuromonitoring practices in Level IV NICUs performing ECMO. Lack of evidence and clear outcome benefits has contributed to practice variation across institutions.
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Bauer Huang SL, Said AS, Smyser CD, Lin JC, Guilliams KP, Guerriero RM. Seizures Are Associated With Brain Injury in Infants Undergoing Extracorporeal Membrane Oxygenation. J Child Neurol 2021; 36:230-236. [PMID: 33112194 PMCID: PMC8086759 DOI: 10.1177/0883073820966917] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Determine seizure frequency and association with neurologic outcomes in infants undergoing extracorporeal membrane oxygenation. Identify patient or clinical factors associated with seizures or brain injury on imaging. METHODS Retrospective, single-center study including infants less than 1 year of age, who underwent extracorporeal membrane oxygenation between 2012 and 2017. RESULTS A total of 104 infants met study criteria including 45 patients with continuous electroencephalographic (EEG) monitoring during their extracorporeal membrane oxygenation run and 59 infants without EEG. Seizures (electrographic-only or electro-clinical) were identified in 18 of the 45 (40%). Among the 18 infants with seizures, 14 (78%) had moderate to severe brain injury, whereas only 44% of those without seizures (12 of 27) on EEG had moderate to severe brain injury (P = .03). Cardiopulmonary resuscitation prior to extracorporeal membrane oxygenation (ECPR), mode of extracorporeal membrane oxygenation, length of stay, survival to discharge, and congenital heart disease were not associated with seizures. One of 10 patients with cyanotic congenital heart disease due to hypoplastic left heart syndrome had seizures compared with 7 of 10 patients with non-hypoplastic left heart syndrome lesions (P = .02). Seizures were associated with moderate to severe brain injury, after adjusting for ECPR and congenital heart disease (P = .04). CONCLUSIONS Electrographic seizures were common in patients undergoing extracorporeal membrane oxygenation and higher than previously reported. Seizures were associated with moderate to severe abnormalities on imaging, after adjusting for ECPR and congenital heart disease. This study adds to recent literature describing the risk of seizures in patients on extracorporeal membrane oxygenation and highlights the presence of brain injuries that may be identified by routine EEG surveillance.
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Affiliation(s)
- Sarah L Bauer Huang
- Department of Neurology, Division of Pediatric and Developmental Neurology, 7548Washington University in St Louis, MO, USA
| | - Ahmed S Said
- Department of Pediatrics, Division of Critical Care Medicine, 7548Washington University in St Louis, MO, USA
| | - Christopher D Smyser
- Department of Neurology, Division of Pediatric and Developmental Neurology, 7548Washington University in St Louis, MO, USA
- Department of Radiology, 7548Washington University in St Louis, MO, USA
| | - John C Lin
- Department of Pediatrics, Division of Critical Care Medicine, 7548Washington University in St Louis, MO, USA
| | - Kristin P Guilliams
- Department of Neurology, Division of Pediatric and Developmental Neurology, 7548Washington University in St Louis, MO, USA
- Department of Pediatrics, Division of Critical Care Medicine, 7548Washington University in St Louis, MO, USA
| | - Réjean M Guerriero
- Department of Neurology, Division of Pediatric and Developmental Neurology, 7548Washington University in St Louis, MO, USA
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29
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Kim F, Bernbaum J, Connelly J, Gerdes M, Hedrick HL, Hoffman C, Rintoul NE, Ziolkowski K, DeMauro SB. Survival and Developmental Outcomes of Neonates Treated with Extracorporeal Membrane Oxygenation: A 10-Year Single-Center Experience. J Pediatr 2021; 229:134-140.e3. [PMID: 33058857 DOI: 10.1016/j.jpeds.2020.10.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate the associations between the primary indication for extracorporeal membrane oxygenation (ECMO) in neonates and neurodevelopmental outcomes at 12 and 24 months of age. STUDY DESIGN This is a retrospective cohort study of neonates treated with ECMO between January 2006 and January 2016 in the Children's Hospital of Philadelphia newborn/infant intensive care unit. Primary indication for ECMO was classified as medical (eg, meconium aspiration syndrome) or surgical (eg, congenital diaphragmatic hernia). Primary study endpoints were assessed with the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III). Groups were compared with standard bivariate testing and multivariable regression. RESULTS A total of 191 neonates met the study's inclusion criteria, including 96 with a medical indication and 95 with a surgical indication. Survival to discharge was 71%, with significantly higher survival in the medical group (82% vs 60%; P = .001). Survivors had high rates of developmental therapies and neurosensory abnormalities. Developmental outcomes were available for 66% at 12 months and 70% at 24 months. Average performance on the Bayley-III was significantly below expected population normative values. Surgical patients had modestly lower the Bayley-III scores over time; most notably, 15% of medical infants and 49% of surgical infants had motor delay at 24 months (P = .03). CONCLUSIONS In this single-center cohort, surgical patients had lower survival rates and higher incidence of motor delays. Strategies to reduce barriers to follow-up and improve rates of postdischarge developmental surveillance and intervention in this high-risk population are needed.
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Affiliation(s)
- Faith Kim
- Division of Neonatology, Department of Pediatrics, New York Presbyterian Children's Hospital of New York/Columbia University Medical Center, New York, NY
| | - Judy Bernbaum
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - James Connelly
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Marsha Gerdes
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Holly L Hedrick
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Casey Hoffman
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Natalie E Rintoul
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Kristina Ziolkowski
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Sara B DeMauro
- Division of Neonatology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.
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30
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Chen S, Fang F, Liu W, Liu C, Xu F. Cerebral Tissue Regional Oxygen Saturation as a Valuable Monitoring Parameter in Pediatric Patients Undergoing Extracorporeal Membrane Oxygenation. Front Pediatr 2021; 9:669683. [PMID: 34178887 PMCID: PMC8220806 DOI: 10.3389/fped.2021.669683] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Accepted: 05/04/2021] [Indexed: 12/16/2022] Open
Abstract
Objective: Brain function monitoring technology for extracorporeal membrane oxygenation (ECMO) support has been developing quite slowly. Our objective was to explore the data distribution, variation trend, and variability of cerebral tissue regional oxygen saturation (CrSO2) in pediatric patients undergoing ECMO. Methods: Eight patients who received venoarterial ECMO (V-A ECMO) were included in our study. All of them accepted continuous CrSO2 monitoring by near-infrared spectroscopy (NIRS) within 12 h of ECMO initiation until ECMO wean. Differences in the CrSO2 distribution characteristic, the variation trend of daily CrSO2, and the variability of CrSO2 for the first 5 days following ECMO initiation were compared between survivors and non-survivors according to pediatric intensive care unit (PICU) mortality. Results: The percentage of time of CrSO2 <60% against the whole monitoring time was significantly lower in survivors in both hemispheres {right: 4.34% [interquartile range (IQR) = 0.39-8.55%] vs. 47.45% [IQR = 36.03-64.52%], p = 0.036; left: 0.40% [IQR = 0.01-1.15%] vs. 30.9% [IQR = 26.92-49.62%], p = 0.036}. Survivors had significantly higher CrSO2 on the first 4 days. Root mean of successive squared differences (RMSSD), the variability variable of CrSO2, was significantly lower in survivors (right: 3.29 ± 0.79 vs. 6.16 ± 0.67, p = 0.002; left: 3.56 ± 1.20 vs. 6.04 ± 1.44, p = 0.039). Conclusion: Lower CrSO2, CrSO2 <60% over a longer period of time, and higher fluctuation of CrSO2 are likely associated with PICU mortality in pediatric patients undergoing V-A ECMO. Clinical Trial Registry: URL: http://www.chictr.org.cn/showproj.aspx?proj=46639, trial registry number: ChiCTR1900028021.
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Affiliation(s)
- Song Chen
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Fang Fang
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Wenjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Chengjun Liu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
| | - Feng Xu
- Department of Critical Care Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, China International Science and Technology Cooperation Base of Child Development and Critical Disorders, Chongqing Key Laboratory of Pediatrics, Chongqing, China
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31
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Baldovsky MD, Okada PJ. Pediatric stroke in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:1578-1586. [PMID: 33392566 PMCID: PMC7771757 DOI: 10.1002/emp2.12275] [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] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 09/08/2020] [Accepted: 09/22/2020] [Indexed: 01/09/2023] Open
Abstract
Strokes are more commonly seen in adults but also occur in the pediatric population. Similar to adult strokes, pediatric strokes are considered medical emergencies and require prompt diagnosis and treatment to maximize favorable outcomes. Unfortunately, the diagnosis of stroke in children is often delayed, commonly because of parental delay or failure to consider stroke in the differential diagnosis. Children, especially young children, often present differently than adults. Much of the treatment for pediatric strokes has been adapted from adult guidelines but the optimal treatment has not been clearly defined. In this article, we review pediatric strokes and the most recent recommendations for treatment.
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Affiliation(s)
- Michael D. Baldovsky
- Division of Pediatric Emergency MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - Pamela J. Okada
- Division of Pediatric Emergency MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
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32
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Yuliati A, Federman M, Rao LM, Chen L, Sim MS, Matsumoto JH. Prevalence of Seizures and Risk Factors for Mortality in a Continuous Cohort of Pediatric Extracorporeal Membrane Oxygenation Patients. Pediatr Crit Care Med 2020; 21:949-958. [PMID: 32590832 DOI: 10.1097/pcc.0000000000002468] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To evaluate the risk factors for mortality in pediatric extracorporeal membrane oxygenation patients. DESIGN Retrospective, single-center study. SETTING PICU and Pediatric cardiothoracic ICU in an urban, quaternary care center. PATIENTS All neonatal and pediatric patients requiring extracorporeal membrane oxygenation at our institution between January 2014 and December 2018, who underwent a standardized continuous electroencephalogram neuromonitoring protocol during most of the duration of extracorporeal membrane oxygenation support. We excluded patients who had extracorporeal membrane oxygenation initiated at another institution. INTERVENTION None. MEASUREMENTS AND MAIN RESULTS Sixty-six children required extracorporeal membrane oxygenation support during this period. Four patients were excluded, three due to lack of electroencephalogram data, one with extracorporeal membrane oxygenation initiated at other institution. In the remaining 62, 11 patients (17%) had seizures, of which 5 (45%) had status epilepticus. Eight of 11 patients (72%) had exclusively electrographic seizures. A total of 33 patients (53.2%) died, of which 22 died during extracorporeal membrane oxygenation course, and one died 3 years after hospital discharge. Mean survival from extracorporeal membrane oxygenation initiation was 766.9 days (standard deviation, 691.7; median, 546.5; interquartile range 1-3, 97.7-1255.0). In multivariate analysis, increased risk of mortality was associated with the use of extracorporeal cardiopulmonary resuscitation (hazard ratio, 4.33; 95% CI, 1.75-10.72; p = 0.002), imaging findings of cerebral edema (hazard ratio, 14.31; 95% CI, 5.18-39.54; p < 0.001), high lactate level (> 100 mg/dL within 2 hr preextracorporeal membrane oxygenation) (hazard ratio, 1.22; 95% CI, 1.03-1.44; p = 0.022), and prolonged deep hypothermic circulatory arrest (hazard ratio, 3.43; 95% CI, 1.65-7.13; p < 0.001). Presence of seizures was associated with imaging findings of cerebral edema (hazard ratio, 4.16; 95% CI, 1.04-16.58; p = 0.04). CONCLUSIONS Seizures are common in children requiring extracorporeal membrane oxygenation support, with a high rate of electrographic seizures and status epilepticus, as in prior studies. Presence of cerebral edema is both risk factor for mortality and seizures. Other risk factors for mortality include extracorporeal cardiopulmonary resuscitation, high lactate levels, and prolonged deep hypothermic circulatory arrest.
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Affiliation(s)
- Asri Yuliati
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Myke Federman
- Department of Pediatrics, Division of Critical Care Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Lekha M Rao
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Lucia Chen
- Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Myung Shin Sim
- Department of Medicine Statistics Core, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Joyce H Matsumoto
- Department of Pediatrics, Division of Pediatric Neurology, David Geffen School of Medicine at UCLA, Los Angeles, CA
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33
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Peluso L, Rechichi S, Franchi F, Pozzebon S, Scolletta S, Brasseur A, Legros B, Vincent JL, Creteur J, Gaspard N, Taccone FS. Electroencephalographic features in patients undergoing extracorporeal membrane oxygenation. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:629. [PMID: 33126887 PMCID: PMC7598240 DOI: 10.1186/s13054-020-03353-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/21/2020] [Indexed: 11/10/2022]
Abstract
Background Neurologic injury is one of the most frequent causes of death in patients undergoing extracorporeal membrane oxygenation (ECMO). As neurological examination is often unreliable in sedated patients, additional neuromonitoring is needed. However, the value of electroencephalogram (EEG) in adult ECMO patients has not been well assessed. Therefore, the aim of this study was to assess the occurrence of electroencephalographic abnormalities in patients treated with extracorporeal membrane oxygenation (ECMO) and their association with 3-month neurologic outcome.
Methods Retrospective analysis of all patients undergoing venous–venous (V–V) or venous–arterial (V–A) ECMO with a concomitant EEG recording (April 2009–December 2018), either recorded intermittently or continuously. EEG background was classified into four categories: mild/moderate encephalopathy (i.e., mostly defined by the presence of reactivity), severe encephalopathy (mostly defined by the absence of reactivity), burst-suppression (BS) and suppressed background. Epileptiform activity (i.e., ictal EEG pattern, sporadic epileptiform discharges or periodic discharges) and asymmetry were also reported. EEG findings were analyzed according to unfavorable neurological outcome (UO, defined as Glasgow Outcome Scale < 4) at 3 months after discharge. Results A total of 139 patients (54 [41–62] years; 60 (43%) male gender) out of 596 met the inclusion criteria and were analyzed. Veno–arterial (V–A) ECMO was used in 98 (71%); UO occurred in 99 (71%) patients. Continuous EEG was performed in 113 (81%) patients. The analysis of EEG background showed that 29 (21%) patients had severe encephalopathy, 4 (3%) had BS and 19 (14%) a suppressed background. In addition, 11 (8%) of patients had seizures or status epilepticus, 10 (7%) had generalized periodic discharges or lateralized periodic discharges, and 27 (19%) had asymmetry on EEG. In the multivariate analysis, the occurrence of ischemic stroke or intracranial hemorrhage (OR 4.57 [1.25–16.74]; p = 0.02) and a suppressed background (OR 10.08 [1.24–82.20]; p = 0.03) were independently associated with UO. After an adjustment for covariates, an increasing probability for UO was observed with more severe EEG background categories. Conclusions In adult patients treated with ECMO, EEG can identify patients with a high likelihood of poor outcome. In particular, suppressed background was independently associated with unfavorable neurological outcome.
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Affiliation(s)
- Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Serena Rechichi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.,Department of Medical Biotechnologies, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy
| | - Federico Franchi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.,Department of Medical Biotechnologies, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy
| | - Selene Pozzebon
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.,Department of Medical Biotechnologies, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy
| | - Sabino Scolletta
- Department of Medical Biotechnologies, Anesthesia and Intensive Care Unit, University of Siena, Via Bracci 1, 53100, Siena, Italy
| | - Alexandre Brasseur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Benjamin Legros
- Department of Neurology Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.,Department of Neurology, Yale University Medical School, 15, York Street, New Haven, CT, 06510, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
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Continuous Monitoring of Cerebral Autoregulation in Children Supported by Extracorporeal Membrane Oxygenation: A Pilot Study. Neurocrit Care 2020; 34:935-945. [PMID: 33029743 DOI: 10.1007/s12028-020-01111-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2020] [Accepted: 09/09/2020] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Cerebral autoregulation (CA) impairment may pose a risk factor for neurological complications among children supported by extracorporeal membrane oxygenation (ECMO). Our first objective was to investigate the feasibility of CA continuous monitoring during ECMO treatment and to describe its evolution over time. The second objective was to analyze the association between CA impairment and neurological outcome. DESIGN Observational prospective study. PATIENTS AND SETTING Twenty-nine children treated with veno-arterial or veno-venous ECMO in the PICU of Nantes University Hospital, France, and the PICU of the IRCCS Giannina Gaslini Institute in Genoa, Italy. MEASUREMENTS A correlation coefficient between the variations of regional cerebral oxygen saturation and the variations of mean arterial blood pressure (MAP) was calculated as an index of CA (cerebral oxygenation reactivity index, COx). A COx > 0.3 was considered as indicative of autoregulation impairment. COx-MAP plots were investigated allowing determining optimal MAP (MAPopt) and limits of autoregulation: lower (LLA) and upper (ULA). Neurological outcome was assessed by the onset of an acute neurological event (ANE) after ECMO start. RESULTS We included 29 children (median age 84 days, weight 4.8 kg). MAPopt, LLA, and ULA were detected in 90.8% (84.3-93.3) of monitoring time. Mean COx was significantly higher during day 1 of ECMO compared to day 2 [0.1 (0.02-0.15) vs. 0.01 (- 0.05 to 0.1), p = 0.002]. Twelve children experienced ANE (34.5%). The mean COx and the percentage of time spent with a COx > 0.3 were significantly higher among ANE+ compared to ANE- patients [0.09 (0.01-0.23) vs. 0.04 (- 0.02 to 0.06), p = 0.04 and 33.3% (24.8-62.1) vs. 20.8% (17.3-23.7) p = 0.001]. ANE+ patients spent significantly more time with MAP below LLA [17.2% (6.5-32.9) vs. 5.6% (3.6-9.9), p = 0.02] and above ULA [13% (5.3-38.4) vs. 4.2% (2.7-7.4), p = 0.004], respectively. CONCLUSION CA assessment is feasible in pediatric ECMO. The first 24 h following ECMO represents the most critical period regarding CA. Impaired autoregulation is significantly more severe among patients who experience ANE.
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Abstract
Neurologic injury is a known and feared complication of extracorporeal membrane oxygenation (ECMO). Neurologic biomarkers may have a role in assisting in early identification of such. Axonal biomarker tau has not been investigated in the pediatric ECMO population. The objective of this study is to evaluate plasma levels of tau in pediatric patients supported with ECMO. Eighteen patients requiring ECMO support in a quaternary pediatric intensive care unit at a university-affiliated children's hospital from October 2015 to February 2017 were enrolled. Patients undergoing extracorporeal cardiopulmonary resuscitation or recent history of bypass were excluded. Plasma tau was measured using enzyme-linked immunosorbent assay. Neuroimaging was reviewed for acute neurologic injury, and tau levels were analyzed to assess for correlation. Tau was significantly higher in ECMO patients than in control subjects. Sixty-one percent of subjects had evidence of acute brain injury on neuroimaging, but tau level did not correlate with injury. Subjects with multifocal injury all experienced infarction and had significantly higher tau levels on ECMO day 3 than patients with isolated injury. In addition, peak tau levels of neuro-injured subjects were compared with controls and noninjured ECMO subjects using receiver operating curve analysis. This study demonstrates preliminary evidence of axonal injury in pediatric ECMO patients.
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Decreased Brain Volumes and Infants With Congenital Heart Disease Undergoing Venoarterial Extracorporeal Membrane Oxygenation. Pediatr Crit Care Med 2020; 21:738-745. [PMID: 32195905 DOI: 10.1097/pcc.0000000000002336] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The aims of this study were to: i) determine the spectrum of brain injury and ii) compare brain volumes between pre- and postoperative brain MRI in the infants receiving extracorporeal membrane oxygenation compared with those who did not require extracorporeal membrane oxygenation. DESIGN Cohort study of infants with D-transposition of the great arteries or single ventricle physiology. Brain volume (cm) was measured using a segmentation of a volumetric T1-weighted gradient echo sequence. Brain imaging findings (intraventricular hemorrhage, white matter injuries, and stroke) were analyzed with respect to known clinical risk factors for brain injury and adverse neurodevelopmental outcomes. Clinical factors were collected by retrospective chart review. The association between brain volume and extracorporeal membrane oxygenation was evaluated using generalized estimating equations to account for repeated measures. SETTING Prospective and single-centered study. PATIENTS One hundred nine infants (median gestational age, 39.1 wk) with D-transposition of the great arteries (n = 77) or single ventricle physiology (n = 32) were studied pre- and postoperatively with MRI as per clinical protocol. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of the 28 infants (26%) receiving extracorporeal membrane oxygenation, 19 (68%) were supported with extracorporeal membrane oxygenation once, and nine (32%) were supported 2-4 times. On postoperative MRI, new white matter injury was found in only five (17%) of the extracorporeal membrane oxygenation infants versus 40 (49%) in the non-extracorporeal membrane oxygenation group (p = 0.073). The rate of stroke (9% vs 10%), intraventricular hemorrhage (24% vs 29%), and hypoxic ischemia (3% vs 14%) did not differ between the non-extracorporeal membrane oxygenation and extracorporeal membrane oxygenation groups (all p > 0.5). Accounting for D-transposition of the great arteries or single ventricle physiology diagnosis, infants requiring extracorporeal membrane oxygenation had slower brain volume with single (β = -1.67) or multiple extracorporeal membrane oxygenation runs ([β = -6.54]; overall interaction p = 0.012). CONCLUSIONS Patients with d-transposition of the great arteries or single ventricle physiology undergoing extracorporeal membrane oxygenation at our center have a similar incidence of brain injury but more significant impairment of perioperative brain volumes than those not requiring extracorporeal membrane oxygenation.
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Berdajs D, von Segesser LK, Maisano F, Milano G, Ferrari E. Performance characteristics of the new Eurosets magnetically suspended centrifugal pump. Perfusion 2020; 36:183-189. [PMID: 32567504 DOI: 10.1177/0267659120931990] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The aim was to evaluate the performance of a newly developed magnetically suspended centrifugal pump head intended for use as a ventricular assistance device with a newly developed extracorporeal membrane oxygenator setup. METHODS In an experimental setup, an extracorporeal membrane oxygenator circuit was established in three calves with a mean weight of 68.2 ± 2.0 kg. A magnetically levitated centrifugal pump was tested, along with a newly designed extracorporeal membrane oxygenator console, at three different flow ranges: (a) 0.0 to 5.2 L/min, (b) 0.0 to 7.1 L/min, and (c) 0.0 to 6.0 L/min. For each setup, the animals were supported by a circuit for 6 h. Blood samples were collected just before caridiopulmonary bypass (CPB) after 10 min on bypass and after 1, 2, 5, and 6 h of perfusion for hemolysis determination and biochemical tests. Values were recorded for blood pressure, mean flow, and pump rotational speed. Analysis of variance was used for repeated measurements. RESULTS Mean pump flows achieved during the three 6 h pump runs for the three pump heads studied were as follows: (a) flow range 0.0 to 5.2 L/min, 3.6 ± 1.5 L/min, (b) flow range 0.0 to 7.1 L/min, 4.9 ± 1.3 L/min, and (c) flow range 0.0 to 6.0 L/min, 3.8 ± 1.5 L/min. Blood trauma, evaluated by plasma hemoglobin and lactate dehydrogenase levels, did not help in detecting any significant hemolysis. Thrombocytes and white blood cell count profiles showed no significant differences between the groups at the end of the 6 h perfusion. At the end of testing, no clot deposition was found in the oxygenator, and there was no evidence of peripheral emboli. CONCLUSION The results suggest that the newly developed magnetically suspended centrifugal pump head provides satisfactory hydrodynamic performance in an acute perfusion scenario without increasing hemolysis.
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Affiliation(s)
- Denis Berdajs
- Department of Cardiac Surgery, University Hospital of Basel, Basel, Switzerland
| | - Ludwig K von Segesser
- Department of Surgery and Anesthesiology, Cardio-Vascular Research, Lausanne, Switzerland
| | - Francesco Maisano
- Department of Cardiac Surgery, University Hospital of Zurich, Zurich, Switzerland
| | - Guiseppina Milano
- Department of Surgery and Anesthesiology, Cardio-Vascular Research, Lausanne, Switzerland
| | - Enrico Ferrari
- Department of Surgery and Anesthesiology, Cardio-Vascular Research, Lausanne, Switzerland
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Thibault C, Naim MY, Abend NS, Licht DJ, Gaynor JW, Xiao R, Massey SL. A retrospective comparison of phenobarbital and levetiracetam for the treatment of seizures following cardiac surgery in neonates. Epilepsia 2020; 61:627-635. [PMID: 32162678 DOI: 10.1111/epi.16469] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 02/07/2020] [Accepted: 02/13/2020] [Indexed: 01/10/2023]
Abstract
OBJECTIVE To compare the safety and efficacy of phenobarbital and levetiracetam in a cohort of neonates with seizures following cardiac surgery. METHODS We performed a retrospective single-center study of consecutive neonates with electrographically confirmed seizures managed with antiseizure medication after cardiac surgery from June 15, 2012 to December 31, 2018. We compared the safety and efficacy of phenobarbital and levetiracetam as first-line therapy. RESULTS First-line therapy was phenobarbital in 31 neonates and levetiracetam in 22 neonates. Phenobarbital was associated with more adverse events (P = .006). Eight neonates (14%) experienced an adverse event related to phenobarbital use, including seven with hypotension and one with respiratory depression. No adverse events were reported with levetiracetam use. The cessation of electrographic seizures was similar in both groups, including 18 neonates (58%) with seizure cessation after phenobarbital and 12 neonates (55%) with seizure cessation after levetiracetam (P = 1.0). The combined cessation rates of phenobarbital and levetiracetam when used as first- or second-line therapy were 58% and 47%, respectively (P = .47). SIGNIFICANCE Phenobarbital was associated with more adverse events than levetiracetam, and the two drugs were equally but incompletely effective in treating electrographically confirmed seizures in neonates following cardiac surgery. Given its more acceptable safety profile and potential noninferiority, levetiracetam may be a reasonable option for first-line therapy for treatment of seizures in this population. Further prospective studies are needed to confirm these results.
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Affiliation(s)
- Céline Thibault
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Maryam Y Naim
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Nicholas S Abend
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania.,Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Daniel J Licht
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
| | - J William Gaynor
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rui Xiao
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Shavonne L Massey
- Departments of Neurology and Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania, Philadelphia, Pennsylvania
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Hetzer R, Javier MFDM, Javier Delmo EM. Pediatric ventricular assist devices: what are the key considerations and requirements? Expert Rev Med Devices 2019; 17:57-74. [PMID: 31779486 DOI: 10.1080/17434440.2020.1699404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Introduction: The development of ventricular assist devices (VADs) have enabled myocardial recovery and improved patient survival until heart transplantation. However, device options remain limited for children and lag in development.Areas covered: This review focuses on the evolution of pediatric VADs in becoming to be an accepted treatment option in advanced heart failure, discusses the classification of VADs available for children, i.e. types of pumps and duration of support, and defines implantation indications and explantation criteria, describes attendant complications and long-term outcome of VAD support. Furthermore, we emphasize the key considerations and requirements in the application of these devices in infants, children and adolescents.Expert opinion: Increasing use of VADs has facilitated a leading edge in management of advanced heart failure either as a bridge to transplantation or as a bridge to myocardial recovery. In newborns and small children, the EXCOR Pediatric VAD remains the only reliable option. In some patients ventricular unloading may lead to complete myocardial recovery. There is a strong need for pumps that are fully implantable, suitable for single ventricle physiology, such as the right ventricle.
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Affiliation(s)
- Roland Hetzer
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
| | | | - Eva Maria Javier Delmo
- Department of Cardiothoracic and Vascular Surgery, Cardio Centrum Berlin, Berlin, Germany
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Pozzebon S, Blandino Ortiz A, Franchi F, Cristallini S, Belliato M, Lheureux O, Brasseur A, Vincent JL, Scolletta S, Creteur J, Taccone FS. Cerebral Near-Infrared Spectroscopy in Adult Patients Undergoing Veno-Arterial Extracorporeal Membrane Oxygenation. Neurocrit Care 2019; 29:94-104. [PMID: 29560599 DOI: 10.1007/s12028-018-0512-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
BACKGROUND Acute cerebral complications (ACC) of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) are associated with poor long-term neurologic outcome. We described the role of rSO2 monitoring in detecting ACC and desaturations and their relationship with poor outcome when employing VA-ECMO. METHODS Retrospective analysis of patients monitored by cerebral frontal near-infrared spectroscopy (NIRS) (CAS Medical Systems Inc., Branford, CT, USA) during VA-ECMO (November 2008-December 2015). ACC was defined as the presence of stroke and/or brain death, while cerebral desaturation as cortical oxygen tissue saturation (rSO2) < 60%. RESULTS Fifty-six of 159 VA-ECMO patients (age 55 [36-60] years) were included; 18 (32%) developed ACC and 36 died (64%). Cerebral desaturation occurred in 43 (74%) patients, who had a higher mortality than those without cerebral desaturation (74 vs. 31%). A high sequential organ failure assessment (SOFA) score on the first day of ECMO (OR 1.40 [95% CIs 1.06-1.84]) and the minimum ECMO blood flow during the first 4 days of therapy (OR 3.05 [1.01-9.17]) were independently associated with the occurrence of cerebral desaturation. Cerebral desaturation occurred more frequently in patients with ACC than others (94 vs. 68%); patients with ACC also had a lower minimal rSO2 over time (49 vs. 54%) and more frequently had high right-left rSO2 differences (33 vs. 8%), which were both independent predictors of ACC. The occurrence of cerebral desaturation (OR 7.93 [1.62-38.74]) and high lactate concentrations during the first 4 days of ECMO support (OR 1.22 [1.03-1.46]) was independently associated with hospital mortality. CONCLUSIONS Monitoring of rSO2 could be considered as an interesting tool to monitor the brain of patients on VA-ECMO.
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Affiliation(s)
- Selene Pozzebon
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Aaron Blandino Ortiz
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Federico Franchi
- Department of Anesthesia and Intensive Care, Università di Siena - Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Stefano Cristallini
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Mirko Belliato
- U.O.C. Anestesia e Rianimazione 1, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Olivier Lheureux
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Alexandre Brasseur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sabino Scolletta
- Department of Anesthesia and Intensive Care, Università di Siena - Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
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Silberman AP, Cheung EW. Neurodevelopmental Outcomes After Neonatal and Pediatric ECMO. CURRENT PEDIATRICS REPORTS 2019. [DOI: 10.1007/s40124-019-00194-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Scholl H, Lutz JA, Kadner A, Schmid RA. Dynamic stenosis of the right main bronchus in a 3-month-old child: a tracheobronchial sleeve resection under venovenous extracorporeal membrane oxygenation. Eur J Cardiothorac Surg 2019; 55:579-581. [PMID: 30052853 DOI: 10.1093/ejcts/ezy256] [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: 05/08/2018] [Revised: 06/18/2018] [Accepted: 06/20/2018] [Indexed: 11/14/2022] Open
Abstract
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.
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Affiliation(s)
- Heiko Scholl
- Division of General Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jon A Lutz
- Division of General Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Kadner
- Department for Cardiovascular Surgery, Centre for Congenital Heart Disease, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ralph A Schmid
- Division of General Thoracic Surgery, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Cerebrovascular Physiology During Pediatric Extracorporeal Membrane Oxygenation: A Multicenter Study Using Transcranial Doppler Ultrasonography. Pediatr Crit Care Med 2019; 20:178-186. [PMID: 30395027 DOI: 10.1097/pcc.0000000000001778] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To explore changes to expected, age-related transcranial Doppler ultrasound variables during pediatric extracorporeal membrane oxygenation. DESIGN Prospective, observational, multicenter study. SETTING Tertiary care PICUs. PATIENTS Children 1 day to 18 years old requiring veno arterial extracorporeal membrane oxygenation. METHODS Participants underwent daily transcranial Doppler ultrasound measurement of bilateral middle cerebral artery flow velocities. Acute neurologic injury was diagnosed if seizures, cerebral hemorrhage, or diffuse cerebral ischemia was detected. MEASUREMENTS AND MAIN RESULTS Fifty-two children were enrolled and analyzed. In the 44 children without acute neurologic injury, there was a significant reduction in systolic flow velocity and mean flow velocity compared with predicted values over time (F [8, 434] = 60.44; p ≤ 0.0001, and F [8, 434] = 17.61; p ≤ 0.0001). Middle cerebral artery systolic flow velocity was lower than predicted on extracorporeal membrane oxygenation days 1-5, and mean flow velocity was lower than predicted on extracorporeal membrane oxygenation days 1-3. In the six infants less than 90 days old suffering diffuse cerebral ischemia, middle cerebral artery systolic flow velocity, mean flow velocity, and diastolic flow velocity from extracorporeal membrane oxygenation days 1-9 were not significantly different when compared with children of similar age in the cohort that did not suffer acute neurologic injury (systolic flow velocity F [8, 52] = 0.6659; p = 0.07 and diastolic flow velocity F [8, 52] = 1.4; p = 0.21 and mean flow velocity F [8, 52] = 1.93; p = 0.07). Pulsatility index was higher in these infants over time than children of similar age in the cohort on extracorporeal membrane oxygenation that did not suffer acute neurologic injury (F [8, 52] = 3.1; p = 0.006). No patient in the study experienced cerebral hemorrhage. CONCLUSIONS Flow velocities in the middle cerebral arteries of children requiring extracorporeal membrane oxygenation are significantly lower than published normative values for critically ill, mechanically ventilated, sedated children. Significant differences in measured systolic flow velocity, diastolic flow velocity, and mean flow velocity were not identified in children suffering ischemic injury compared with those who did not. However, increased pulsatility index may be a marker for ischemic injury in young infants on extracorporeal membrane oxygenation.
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Di Leo V, Biban P, Mercolini F, Martinolli F, Pettenazzo A, Perilongo G, Amigoni A. The quality of life in extracorporeal life support survivors: single-center experience of a long-term follow-up. Childs Nerv Syst 2019; 35:227-235. [PMID: 30415313 DOI: 10.1007/s00381-018-3999-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 10/31/2018] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the health-related quality of life on a very long-term follow-up in patients treated with extracorporeal membrane oxygenation (ECMO) during neonatal and pediatric age. DESIGN Prospective follow-up study. SETTING Pediatric Intensive Care Unit of a tertiary-care University-Hospital. PATIENTS Out of 20 neonates and 21 children treated with ECMO in our center, 24 patients underwent short-term neurological follow-up. Twenty of them underwent long-term neurological follow-up. INTERVENTION Short-term follow-up was performed at 18 months and consisted in clinical evaluation, electroencephalography, and neuroimaging. Long-term follow-up was performed in 2017, at the mean period 19.72 years from ECMO (median 20.75, range 11.50-24.08) and consisted in a standardized questionnaires self-evaluation (PedsQL 4.0 Generic Core Scale) of health-related quality of life and an interviewed about the presence of organ morbidity, school level, or work position. MEASUREMENTS AND MAIN RESULTS Sixty-one percent (25/41) of the patients survived within 30 days after ECMO treatment. Short-term follow-up was performed in 24 patients (1 patient but died before the evaluation): 21 patients (87%) showed a normal neurological status, and 3 developed severe disability. Long-term follow-up was performed in 20 long-term survivors (3 patients were not possible to be contacted and considered lost to follow-up): mean age of patients at long-term follow-up was 21.23 (median 20.96, range 13.33-35.58) years; 90% (18/20) of them have no disability with a complete normal quality of life and 95% have no cognitive impairment. CONCLUSIONS ECMO represents a life-saving treatment for infants and children with respiratory and/or heart failure; survivors show a good quality of life comparable to healthy peers.
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Affiliation(s)
- Valentina Di Leo
- Pediatric Intensive Care Unit, Woman's and Child's Health Department, University Hospital, Via Giustiniani 3, 35128, Padua, Italy
| | - Paolo Biban
- Neonatal and Pediatric Intensive Care Unit, Department of Pediatric, University Hospital, Verona, Italy
| | - Federico Mercolini
- Pediatric Intensive Care Unit, Woman's and Child's Health Department, University Hospital, Via Giustiniani 3, 35128, Padua, Italy
| | - Francesco Martinolli
- Pediatric Intensive Care Unit, Woman's and Child's Health Department, University Hospital, Via Giustiniani 3, 35128, Padua, Italy
| | - Andrea Pettenazzo
- Pediatric Intensive Care Unit, Woman's and Child's Health Department, University Hospital, Via Giustiniani 3, 35128, Padua, Italy
| | - G Perilongo
- Woman's and Child's Department, University Hospital, Padua, Italy
| | - Angela Amigoni
- Pediatric Intensive Care Unit, Woman's and Child's Health Department, University Hospital, Via Giustiniani 3, 35128, Padua, Italy.
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Prevalence of Seizures in Pediatric Extracorporeal Membrane Oxygenation Patients as Measured by Continuous Electroencephalography. Pediatr Crit Care Med 2018; 19:1162-1167. [PMID: 30247227 DOI: 10.1097/pcc.0000000000001730] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Standards for neuromonitoring during extracorporeal membrane oxygenation support do not currently exist, and there is wide variability in practice. We present our institutional experience at an academic children's hospital since establishment of a continuous electroencephalography monitoring protocol for extracorporeal membrane oxygenation patients. DESIGN Retrospective, single-center study. SETTING Neonatal ICU and PICU in an urban, quaternary care center. PATIENTS All neonatal and pediatric patients requiring extracorporeal membrane oxygenation. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS During the study period, 70 patients were cannulated for extracorporeal membrane oxygenation and had continuous electroencephalography monitoring for greater than 24 hours. Electroencephalographic seizures were observed in 16 of 70 patients (23%), including five patients (7%) who were in status epilepticus. Among patients with continuous electroencephalography seizures, nine (56%) had subclinical nonconvulsive status epilepticus and eight (50%) had seizures in the initial 24 hours of extracorporeal membrane oxygenation support. Survival to hospital discharge was significantly greater for extracorporeal membrane oxygenation patients without seizures (74% vs 44%; p = 0.02). CONCLUSIONS Seizures occur in a significant proportion of pediatric and neonatal extracorporeal membrane oxygenation patients, frequently in the initial 24 hours after extracorporeal membrane oxygenation cannulation. Because seizures are associated with significantly decreased survival, neuromonitoring early in the extracorporeal membrane oxygenation course is important and useful. Further studies are needed to correlate electroencephalography findings with neurologic outcome.
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Craniectomy and Traumatic Brain Injury in Children on Extracorporeal Membrane Oxygenation Support. Pediatr Emerg Care 2018; 34:e204-e210. [PMID: 27749813 DOI: 10.1097/pec.0000000000000907] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Severe trauma may cause refractory life-threatening respiratory failure requiring extracorporeal membrane oxygenation (ECMO). Concurrent traumatic brain injury, however, complicates the use of ECMO because of the major risk of intracranial bleeding with systemic anticoagulation. Craniotomy and/or craniectomy for hematoma evacuation during ECMO are extremely high-risk procedures secondary to ongoing anticoagulation, and there are only a few such case reports in the literature. We present the case of a child with multiple thoracic injuries and life-threatening respiratory failure supported on ECMO. She developed an intracranial hemorrhage while systemically heparinized that required emergent decannulation and bedside craniectomy for hematoma extraction. She survived with an excellent neurologic outcome. We also review the relevant literature regarding the use of ECMO in patients with polytrauma and the occurrence of craniectomy on extracorporeal support, with a focus on pediatric publications. Patients with polytrauma with brain injury can be supported on ECMO, but extreme precaution must be taken regarding anticoagulation. The intracranial complications of ECMO in this population are not infrequent, but our case report and review of the literature suggest that neurosurgical intervention should be considered in life-threatening conditions when no other alternatives are available.
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Tan AP, Svrckova P, Cowan F, Chong WK, Mankad K. Intracranial hemorrhage in neonates: A review of etiologies, patterns and predicted clinical outcomes. Eur J Paediatr Neurol 2018; 22:690-717. [PMID: 29731328 DOI: 10.1016/j.ejpn.2018.04.008] [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] [Received: 08/13/2017] [Revised: 03/31/2018] [Accepted: 04/18/2018] [Indexed: 12/29/2022]
Abstract
Intracranial hemorrhage (ICH) in neonates often results in devastating neurodevelopmental outcomes as the neonatal period is a critical window for brain development. The neurodevelopmental outcomes in neonates with ICH are determined by the maturity of the brain, the location and extent of the hemorrhage, the specific underlying etiology and the presence of other concomitant disorders. Neonatal ICH may result from various inherited and acquired disorders. We classify the etiologies of neonatal ICH into eight main categories: (1) Hemorrhagic stroke including large focal hematoma, (2) Prematurity-related hemorrhage, (3) Bleeding diathesis, (4) Genetic causes, (5) Infection, (6) Trauma-related hemorrhage, (7) Tumor-related hemorrhage and (8) Vascular malformations. Illustrative cases showing various imaging patterns that can be helpful to predict clinical outcomes will be highlighted. Potential mimics of ICH in the neonatal period are also reviewed.
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Affiliation(s)
- Ai Peng Tan
- Department of Diagnostic Imaging, National University Health System, 1E Kent Ridge Rd 119228, Singapore.
| | - Patricia Svrckova
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London WC1N 3JH, UK.
| | - Frances Cowan
- Dept. of Neonatology, Chelsea and Westminster Hospital NHS Foundation Trust, Imperial College, London, SW10 9NH, UK.
| | - Wui Khean Chong
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London WC1N 3JH, UK.
| | - Kshitij Mankad
- Department of Radiology, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond St, London WC1N 3JH, UK.
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Coagulation Profile Is Not a Predictor of Acute Cerebrovascular Events in Pediatric Extracorporeal Membrane Oxygenation Patients. ASAIO J 2018; 63:793-801. [PMID: 28678046 DOI: 10.1097/mat.0000000000000571] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We performed a retrospective matched case-control study evaluating whether the traditional coagulation profile predicts cerebrovascular events in children on extracorporeal membrane oxygenation (ECMO) in a 71 bed intensive care unit at a tertiary children's hospital. Between 2009 and 2014, 241 neonates and children were initiated on ECMO. The cumulative 5 year incidence of intracranial hemorrhage and infarct was 9.2% and 7.9%, respectively. Thirty-six cases were individually matched 1:1 with control subjects based on age, primary diagnosis, ECMO type, cannulation site, and the presence of pre-ECMO coagulopathy. In-hospital mortality was higher among the cases compared with control subjects (78 vs. 22%, p < 0.01). The median laboratory values that assisted with heparin anticoagulation monitoring (activated clotting time, partial thromboplastin time, and antifactor Xa) and the laboratory data that assisted with blood product administration (platelet count, prothrombin time, fibrinogen, and d-dimer) during the 24 and 72 hour periods before the cerebrovascular event did not show any significant difference between the hemorrhage group and their controls or between the infarct group and their controls. The traditional coagulation profile did not predict acute cerebrovascular events in our cohort. Other markers of neurologic injury on ECMO are yet to be elucidated. Prospective studies to determine better predictors of cerebrovascular complications in pediatric ECMO patients are required.
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Brain Magnetic Resonance Imaging Findings in Pediatric Patients Post Extracorporeal Membrane Oxygenation. ASAIO J 2018; 63:810-814. [PMID: 29084038 DOI: 10.1097/mat.0000000000000580] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Neurologic complications can occur with extracorporeal membrane oxygenation (ECMO) due to several factors. Prior studies identified neonates as having unique risk factors and neuroimaging findings post ECMO. The aim of this study is to describe brain magnetic resonance imaging findings of pediatric patients treated with ECMO. We conducted a retrospective study of nonneonatal pediatric patients who underwent a comprehensive brain magnetic resonance imaging after ECMO between January 2000 and July 2015. We identified 47 pediatric patients in the study cohort with a median age of 8 months (interquartile range 3-170 months) and a median ECMO run duration of 7.15 days (interquartile range 3.8-10.3 days). Among indications for ECMO cannulation, 12 (25.5%) were cardiac, 23 (48.9%) were respiratory, and 12 (25.5%) were extracorporeal cardiopulmonary resuscitation cannulations. There were 33 (70.2%) veno-arterial cannulations of which 14 (42%) were transthoracic cannulations. There were 13 patients (27.7%) with an overall incidence of stroke: 8 patients had exclusive ischemic strokes, 2 had hemorrhagic strokes, and 3 had mixed types of stroke. The number of strokes in patients on veno-arterial ECMO was significantly decreased in patients undergoing transthoracic cannulation when compared with peripheral cannulation (7 vs. 42%, p = 0.05). Further study will be used to identify risk factors for neurological injury after ECMO and to look for outcome predictors based on neuroradiologic findings.
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Survival and Long-Term Functional Outcomes for Children With Cardiac Arrest Treated With Extracorporeal Cardiopulmonary Resuscitation. Pediatr Crit Care Med 2018; 19. [PMID: 29528976 PMCID: PMC5935542 DOI: 10.1097/pcc.0000000000001524] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To identify patient- and disease-related factors related to survival and favorable outcomes for children who underwent extracorporeal cardiopulmonary resuscitation after a refractory cardiac arrest. DESIGN Retrospective observational study with prospective assessment of long-term functional outcome. PATIENTS Fifty-six consecutive children undergoing extracorporeal cardiopulmonary resuscitation at our institution from 2007 to 2015. Median age at arrest was 3.5 months (interquartile range, 1-53). SETTING Tertiary pediatric university hospital with a referral heart center. INTERVENTIONS Health-related quality of life and family functioning assessment with the Pediatric Quality of Life Inventory and the McMaster Family Assessment Device. MEASUREMENTS AND MAIN RESULTS Fifty-eight consecutive extracorporeal cardiopulmonary resuscitation episodes were included, with 46 (79.3%) related to primary cardiac conditions. Initial cannulation site was central in 19 (32.8%) and peripheral in 39 (67.2%). Survival to decannulation was 77.6% with survival at hospital discharge and at the end of the follow-up period being 65.5% and 62.1%, respectively. Time to follow-up was 38 months (interquartile range, 19-52). Patients who survived tended to be younger (3.5 mo [1 mo to 2 yr] vs 7 mo [1.25 mo to 17 yr]; p = 0.3) with decreased extracorporeal cardiopulmonary resuscitation times (28 min [15-47 min] vs 37.5 min [28.5-55 min]; p = 0.04). Those who received therapeutic hypothermia tended to have higher hospital survival (21/28 [75%] vs 16/29 [55%]; p = 0.08). Follow-up assessments of survivors demonstrated good quality of life and family functioning (Pediatric Quality of Life Inventory, 84 [76-89.5]; McMaster Family Assessment Device, 1.62 [1.33-1.83]). CONCLUSIONS In this series, extracorporeal cardiopulmonary resuscitation was associated with relatively high survival rates and a good health-related quality of life and family functioning. Larger series are needed to assess whether this technique should be more broadly available in the pediatric critical care community.
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