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Delgado-Corcoran C, Wawrzynski SE, Flaherty B, Kirkland B, Bodily S, Moore D, Cook LJ, Olson LM. Extracorporeal membrane oxygenation and paediatric palliative care in an ICU. Cardiol Young 2023; 33:1846-1852. [PMID: 36278475 DOI: 10.1017/s1047951122003018] [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] [Indexed: 11/07/2022]
Abstract
OBJECTIVES Compare rates, clinical characteristics, and outcomes of paediatric palliative care consultation in children supported on extracorporeal membrane oxygenation admitted to a single-centre 16-bed cardiac or a 28-bed paediatric ICU. METHODS Retrospective review of clinical characteristics and outcomes of children (aged 0-21 years) supported on extracorporeal membrane oxygenation between January, 2017 and December, 2019 compared by palliative care consultation. MEASUREMENTS AND RESULTS One hundred children (N = 100) were supported with extracorporeal membrane oxygenation; 19% received a palliative care consult. Compared to non-consulted children, consulted children had higher disease severity measured by higher complex chronic conditions at the end of extracorporeal membrane oxygenation hospitalisation (5 versus. 3; p < 0.001), longer hospital length of stay (92 days versus 19 days; p < 0.001), and higher use of life-sustaining therapies after decannulation (79% versus 23%; p < 0.001). Consultations occurred mainly for longitudinal psychosocial-spiritual support after patient survived device deployment with a median of 27 days after cannulation. Most children died in the ICU after withdrawal of life-sustaining therapies regardless of consultation status. Over two-thirds of the 44 deaths (84%; n = 37) occurred during extracorporeal membrane oxygenation hospitalisation. CONCLUSIONS Palliative care consultation was rare showing that palliative care consultation was not viewed as an acute need and only considered when the clinical course became protracted. As a result, there are missed opportunities to involve palliative care earlier and more frequently in the care of extracorporeal membrane survivors and non-survivors and their families.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
- University of Utah, College of Nursing, 10 S 2000 E, Salt Lake City, UT, USA
| | - Brian Flaherty
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
| | - Brandon Kirkland
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
| | - Stephanie Bodily
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Dominic Moore
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, 100 N. Mario Capecchi Dr. Salt Lake City, UT, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, 295 Chipeta Way, PO BOX 581289, Salt Lake City, UT, USA
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Osakwe O, Das BB. Successful recovery after blade atrial septostomy in a child with pulmonary hypertensive crisis and cardiac arrest requiring extracorporeal cardiopulmonary resuscitation. PROGRESS IN PEDIATRIC CARDIOLOGY 2022. [DOI: 10.1016/j.ppedcard.2022.101572] [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: 11/26/2022]
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3
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Delgado-Corcoran C, Wawrzynski SE, Mansfield KJ, Flaherty B, DeCourcey DD, Moore D, Cook LJ, Ullrich CK, Olson LM. An Automatic Pediatric Palliative Care Consultation for Children Supported on Extracorporeal Membrane Oxygenation: A Survey of Perceived Benefits and Barriers. J Palliat Med 2022; 25:952-957. [PMID: 35319287 DOI: 10.1089/jpm.2021.0452] [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: 11/12/2022] Open
Abstract
Background: Pediatric palliative care (PPC) consultation is infrequent among children on extracorporeal membrane oxygenation (ECMO). Objective: Investigate intensive care unit (ICU) team members' perceptions of automatic PPC consultation for children on ECMO in an ICU in the United States. Methods: Cross-sectional survey assessing benefits, barriers to PPC, and consultation processes. Results: Of 291 eligible respondents, 48% (n = 140) completed the survey and 16% (n = 47) answered an open-ended question. Benefits included support in decision-making (n = 98; 70%) and identification of goals of care (n = 89; 64%). Barriers included perception of giving up on families (n = 59; 42%) and poor acceptability by other team members (n = 58; 41%). Respondents endorsed communication with the primary ICU team before (n = 122; 87%) and after (n = 129; 92%) consultation. Open-ended responses showed more positive (79% vs. 13%) than negative statements. Positive statements reflected on expanding PPC to other critically-ill children where negative statements revealed unrecognized value in PPC. Conclusions: Results demonstrate opportunities for education about the scope of PPC and improvements in PPC delivery.
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Affiliation(s)
- Claudia Delgado-Corcoran
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.,Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Sarah E Wawrzynski
- Pediatric Critical Care Services, Primary Children's Hospital, Intermountain Healthcare, Salt Lake City, Utah, USA.,College of Nursing, University of Utah, Salt Lake City, Utah, USA
| | | | - Brian Flaherty
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Danielle D DeCourcey
- Division of Medical Critical Care, Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dominic Moore
- Division of Pediatric Palliative Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Lawrence J Cook
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
| | - Christina K Ullrich
- Division of Pediatric Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Hematology/Oncology, Boston Children's Hospital, Boston, Massachusetts, USA.,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts, USA
| | - Lenora M Olson
- Division of Critical Care, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA
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4
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Di Nardo M, Ahmad AH, Merli P, Zinter MS, Lehman LE, Rowan CM, Steiner ME, Hingorani S, Angelo JR, Abdel-Azim H, Khazal SJ, Shoberu B, McArthur J, Bajwa R, Ghafoor S, Shah SH, Sandhu H, Moody K, Brown BD, Mireles ME, Steppan D, Olson T, Raman L, Bridges B, Duncan CN, Choi SW, Swinford R, Paden M, Fortenberry JD, Peek G, Tissieres P, De Luca D, Locatelli F, Corbacioglu S, Kneyber M, Franceschini A, Nadel S, Kumpf M, Loreti A, Wösten-Van Asperen R, Gawronski O, Brierley J, MacLaren G, Mahadeo KM. Extracorporeal membrane oxygenation in children receiving haematopoietic cell transplantation and immune effector cell therapy: an international and multidisciplinary consensus statement. THE LANCET. CHILD & ADOLESCENT HEALTH 2022; 6:116-128. [PMID: 34895512 PMCID: PMC9372796 DOI: 10.1016/s2352-4642(21)00336-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/12/2021] [Accepted: 10/19/2021] [Indexed: 01/03/2023]
Abstract
Use of extracorporeal membrane oxygenation (ECMO) in children receiving haematopoietic cell transplantation (HCT) and immune effector cell therapy is controversial and evidence-based guidelines have not been established. Remarkable advancements in HCT and immune effector cell therapies have changed expectations around reversibility of organ dysfunction and survival for affected patients. Herein, members of the Extracorporeal Life Support Organization (ELSO), Pediatric Acute Lung Injury and Sepsis Investigators (PALISI) Network (HCT and cancer immunotherapy subgroup), the Pediatric Diseases Working Party of the European Society for Blood and Marrow Transplantation (EBMT), the supportive care committee of the Pediatric Transplantation and Cellular Therapy Consortium (PTCTC), and the Pediatric Intensive Care Oncology Kids in Europe Research (POKER) group of the European Society of Pediatric and Neonatal Intensive Care (ESPNIC) provide consensus recommendations on the use of ECMO in children receiving HCT and immune effector cell therapy. These are the first international, multidisciplinary consensus-based recommendations on the use of ECMO in this patient population. This Review provides a clinical decision support tool for paediatric haematologists, oncologists, and critical care physicians during the difficult decision-making process of ECMO candidacy and management. These recommendations can represent a base for future research studies focused on ECMO selection criteria and bedside management.
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Affiliation(s)
- Matteo Di Nardo
- Pediatric Intensive Care Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy.
| | - Ali H Ahmad
- Department of Pediatrics, Pediatric Critical Care, Houston, TX, USA
| | - Pietro Merli
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Matthew S Zinter
- Department of Pediatrics, Divisions of Critical Care and Bone Marrow Transplantation, University of California, San Francisco, CA, USA
| | - Leslie E Lehman
- Pediatric Hematology-Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Courtney M Rowan
- Department of Pediatrics, Division of Critical Care, Indiana University School of Medicine, Riley Hospital for Children, Indianapolis, IN, USA
| | - Marie E Steiner
- Department of Pediatrics, University of Minnesota, Minneapolis, MN, USA
| | - Sangeeta Hingorani
- Department of Pediatrics, Division of Nephrology, University of Washington School of Medicine, and the Clinical Research Division, Fred Hutchinson Cancer Research Center, Seattle, WA, USA
| | - Joseph R Angelo
- Renal Section, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Hisham Abdel-Azim
- Department of Pediatrics, Transplantation and Cell Therapy Program, Keck School of Medicine, University of Southern California, Children's Hospital Los Angeles, Los Angeles, CA, USA
| | - Sajad J Khazal
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Basirat Shoberu
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jennifer McArthur
- Division of Critical Care Medicine, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Rajinder Bajwa
- Department of Pediatrics, Division of Blood and Marrow Transplantation, Nationwide Children's Hospital, The Ohio State University, Columbus, OH, USA
| | - Saad Ghafoor
- Division of Critical Care Medicine, Department of Pediatric Medicine, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Samir H Shah
- Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Hitesh Sandhu
- Division of Pediatric Critical Care Medicine, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Karen Moody
- CARTOX Program, and Department of Pediatrics, Supportive Care, Houston, TX, USA
| | - Brandon D Brown
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | | | - Diana Steppan
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Taylor Olson
- Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Lakshmi Raman
- Department of Pediatrics, UT Southwestern Medical Center, Dallas, TX, USA
| | - Brian Bridges
- Division of Pediatric Critical Care, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Christine N Duncan
- Pediatric Hematology-Oncology, Dana-Farber Cancer Institute, Harvard University, Boston, MA, USA
| | - Sung Won Choi
- University of Michigan, Rogel Cancer Center, Ann Arbor, MI, USA; Department of Pediatrics, Ann Arbor, MI, USA
| | - Rita Swinford
- Department of Pediatrics, Division of Pediatric Nephrology, McGovern Medical School, The University of Texas Health Science Center, Houston, TX, USA
| | - Matt Paden
- Pediatric Critical Care, Children's Healthcare of Atlanta, and Emory University School of Medicine, Atlanta, GA, USA
| | - James D Fortenberry
- Pediatric Critical Care, Children's Healthcare of Atlanta, and Emory University School of Medicine, Atlanta, GA, USA
| | - Giles Peek
- Congenital Heart Center, University of Florida, Gainesville, FL, USA
| | - Pierre Tissieres
- Division of Pediatric Intensive Care and Neonatal Medicine, Paris South University Hospital, Le Kremlin-Bicetre, France; Institute of Integrative Biology of the Cell, CNRS, CEA, Univ. Paris Sud, Paris Saclay University, Paris, France
| | - Daniele De Luca
- Division of Pediatrics, Transportation and Neonatal Critical Care Medicine, APHP, Paris Saclay University Hospital, "A.Beclere" Medical Center and Physiopathology and Therapeutic Innovation Unit-INSERM-U999, Paris Saclay University, Paris, France
| | - Franco Locatelli
- Department of Hematology/Oncology, Cell and Gene Therapy, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Selim Corbacioglu
- Department of Pediatric Hematology, Oncology and Stem Cell Transplantation, University of Regensburg, Regensburg, Germany
| | - Martin Kneyber
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Beatrix Children's Hospital Groningen, Groningen, Netherlands; Critical Care, Anesthesiology, Peri-Operative and Emergency Medicine (CAPE), University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Alessio Franceschini
- Department of Cardiosurgery, Cardiology, Heart and Lung Transplant, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Simon Nadel
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Matthias Kumpf
- Interdisciplinary Pediatric Intensive Care Unit, Universitäetsklinikum Tuebingen, Tuebingen, Germany
| | - Alessandra Loreti
- Medical Library, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Roelie Wösten-Van Asperen
- Department of Pediatric Intensive Care, University Medical Center Utrecht/Wilhelmina Children's Hospital, Utrecht, Netherlands
| | - Orsola Gawronski
- Professional Development, Continuing Education and Research Unit, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Joe Brierley
- Department of Pediatric Intensive Care, Great Ormond Street Hospital for Children, London, UK
| | - Graeme MacLaren
- Director of Cardiothoracic ICU, National University Health System, Singapore, Singapore; Pediatric Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Kris M Mahadeo
- Department of Pediatrics, Stem Cell Transplantation and Cellular Therapy, Houston, TX, USA; The University of Texas MD Anderson Cancer Center, Houston, TX, USA
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6
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Cho HJ, Choi I, Kwak Y, Kim DW, Habimana R, Jeong IS. The Outcome of Post-cardiotomy Extracorporeal Membrane Oxygenation in Neonates and Pediatric Patients: A Systematic Review and Meta-Analysis. Front Pediatr 2022; 10:869283. [PMID: 35547551 PMCID: PMC9083359 DOI: 10.3389/fped.2022.869283] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 03/28/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE Post-cardiotomy extracorporeal membrane oxygenation (PC-ECMO) is a known rescue therapy for neonates and pediatric patients who failed to wean from cardiopulmonary bypass (CPB) or who deteriorate in intensive care unit (ICU) due to various reasons such as low cardiac output syndrome (LCOS), cardiac arrest and respiratory failure. We conducted a systematic review and meta-analysis to assess the survival in neonates and pediatric patients who require PC-ECMO and sought the difference in survivals by each indication for PC-ECMO. DESIGN Systematic review and meta-analysis. SETTING Multi-institutional analysis. PARTICIPANTS Neonates and pediatric patients who requires PC- ECMO. INTERVENTIONS ECMO after open-heart surgery. RESULTS Twenty-six studies were included in the analysis with a total of 186,648 patients and the proportion of the population who underwent PC-ECMO was 2.5% (2,683 patients). The overall pooled proportion of survival in this population was 43.3% [95% Confidence interval (CI): 41.3-45.3%; I 2: 1%]. The survival by indications of PC-ECMO were 44.6% (95% CI: 42.6-46.6; I 2: 0%) for CPB weaning failure, 47.3% (95% CI: 39.9-54.7%; I 2: 5%) for LCOS, 37.6% (95% CI: 31.0-44.3%; I 2: 32%) for cardiac arrest and 47.7% (95% CI: 32.5-63.1%; I 2: 0%) for respiratory failure. Survival from PC-ECMO for single ventricle or biventricular physiology, was reported by 12 studies. The risk ratio (RR) was 0.74 for survival in patients with single ventricle physiology (95% CI: 0.63-0.86; I 2: 40%, P < 0.001). Eight studies reported on the survival after PC-ECMO for genetic conditions. The RR was 0.93 for survival in patients with genetic condition (95% CI: 0.52-1.65; I 2: 65%, P = 0.812). CONCLUSIONS PC-ECMO is an effective modality to support neonates and pediatric patients in case of failed CPB weaning and deterioration in ICU. Even though ECMO seems to improve survival, mortality and morbidity remain high, especially in neonates and pediatric patients with single ventricle physiology. Most genetic conditions alone should not be considered a contraindication to ECMO support, further studies are needed to determine which genetic abnormalities are associated with favorable outcome.
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Affiliation(s)
- Hwa Jin Cho
- Division of Pediatric Cardiology and Cardiac Critical Care, Department of Pediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, South Korea.,Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea
| | - Insu Choi
- Division of Pediatric Cardiology and Cardiac Critical Care, Department of Pediatrics, Chonnam National University Children's Hospital and Medical School, Gwangju, South Korea
| | - Yujin Kwak
- Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | - Do Wan Kim
- Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea.,Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
| | - Reverien Habimana
- Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea.,Department of Biomedical Sciences, College of Medicine, Chonnam National University Graduate School, Gwangju, South Korea
| | - In-Seok Jeong
- Cardiovascular and Respiratory Research Team, Chonnam National University Hospital, Gwangju, South Korea.,Department of Thoracic and Cardiovascular Surgery, Chonnam National University Hospital and Medical School, Gwangju, South Korea
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Extrakorporale Membranoxygenierung und „extracorporeal life support“ im Kindesalter und bei angeborenen Herzfehlern. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2021. [DOI: 10.1007/s00398-021-00440-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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8
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Amodeo I, Di Nardo M, Raffaeli G, Kamel S, Macchini F, Amodeo A, Mosca F, Cavallaro G. Neonatal respiratory and cardiac ECMO in Europe. Eur J Pediatr 2021; 180:1675-1692. [PMID: 33547504 PMCID: PMC7864623 DOI: 10.1007/s00431-020-03898-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Revised: 11/25/2020] [Accepted: 11/30/2020] [Indexed: 11/28/2022]
Abstract
Neonatal extracorporeal membrane oxygenation (ECMO) is a life-saving procedure for critically ill neonates suffering from a potentially reversible disease, causing severe cardiac and/or respiratory failure and refractory to maximal conventional management. Since the 1970s, technology, management, and clinical applications of neonatal ECMO have changed. Pulmonary diseases still represent the principal neonatal diagnosis, with an overall 74% survival rate, and up to one-third of cases are due to congenital diaphragmatic hernia. The overall survival rate in cardiac ECMO is lower, with congenital heart defect representing the main indication. This review provides an overview of the available evidence in the field of neonatal ECMO. We will address the changing epidemiology, basic principles, technologic advances in circuitry, and monitoring, and deliver a current multidisciplinary management framework, focusing on ECMO applications, complications, and long-term morbidities. Lastly, areas for further research will be highlighted.Conclusions: ECMO is a life support with a potential impact on long-term patients' outcomes. In the next years, advances in knowledge, technology, and expertise may push neonatal ECMO boundaries towards more premature and increasingly complex infants, with the final aim to reduce the burden of ECMO-related complications and improve overall patients' outcomes. What is Known: • ECMO is a life-saving option in newborns with refractory respiratory and/or cardiac failure. • The multidisciplinary ECMO management is challenging and may expose neonates to complications with an impact on long-term outcomes. What is New: • Advances in technology and biomaterials will improve neonatal ECMO management and, eventually, the long-term outcome of these complex patients. • Experimental models of artificial placenta and womb technology are under investigation and may provide clinical translation and future research opportunities.
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Affiliation(s)
- Ilaria Amodeo
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
| | | | - Genny Raffaeli
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Shady Kamel
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
- Betamed Perfusion Service, Rome, Italy
| | - Francesco Macchini
- Department of Pediatric Surgery, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Antonio Amodeo
- ECMO & VAD Unit, Bambino Gesù Children’s Hospital, IRCCS, Rome, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Della Commenda 12, 20122 Milan, Italy
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Successful combination treatment with transcatheter balloon atrioseptostomy and bilateral pulmonary artery banding in a collapsed preterm neonate. Cardiol Young 2021; 31:867-869. [PMID: 33507139 DOI: 10.1017/s1047951120004977] [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] [Indexed: 11/08/2022]
Abstract
There has been an increase in the use of extracorporeal membrane oxygenation for severe neonatal cardiac failure. However, the frequency of complications is high, particularly in preterm and low-birth-weight neonates. Herein, we present combination treatment with transcatheter balloon atrioseptostomy and bilateral pulmonary artery banding in a collapsed preterm neonate. This strategy can be an alternative to circulatory support using extracorporeal membrane oxygenation.
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10
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Brown G, Moynihan KM, Deatrick KB, Hoskote A, Sandhu HS, Aganga D, Deshpande SR, Menon AP, Rozen T, Raman L, Alexander PMA. Extracorporeal Life Support Organization (ELSO): Guidelines for Pediatric Cardiac Failure. ASAIO J 2021; 67:463-475. [PMID: 33788796 DOI: 10.1097/mat.0000000000001431] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
These guidelines are applicable to neonates and children with cardiac failure as indication for extracorporeal life support. These guidelines address patient selection, management during extracorporeal membrane oxygenation, and pathways for weaning support or bridging to other therapies. Equally important issues, such as personnel, training, credentialing, resources, follow-up, reporting, and quality assurance, are addressed in other Extracorporeal Life Support Organization documents or are center-specific.
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Affiliation(s)
- Georgia Brown
- From the Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Katie M Moynihan
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Kristopher B Deatrick
- Division of Cardiac Surgery, University of Maryland School of Medicine, Baltimore, Maryland
| | - Aparna Hoskote
- Cardiorespiratory and Critical Care Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Hitesh S Sandhu
- Department of Pediatrics, Critical Care Division, Le Bonheur Children's Hospital, University of Tennessee, Memphis, Tennessee
| | - Devon Aganga
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
- Department of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
| | - Shriprasad R Deshpande
- Pediatric Cardiology Division, Heart Transplant and Advanced Cardiac Therapies Program, Children's National Heart Institute, Washington, D.C
| | - Anuradha P Menon
- Children's Intensive Care Unit, Department of Paediatric Subspecialties, KK Women's and Children's Hospital, Singapore
| | - Thomas Rozen
- From the Cardiac Intensive Care Unit, The Royal Children's Hospital, Melbourne, Australia
| | - Lakshmi Raman
- Department of Critical Care, University of Texas Southwestern Medical Center, Texas
| | - Peta M A Alexander
- Department of Cardiology, Boston Children's Hospital, Boston, Massachusetts
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
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11
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Extracorporeal Membrane Oxygenation during Percutaneous Coronary Intervention in Patients with Coronary Heart Disease. THE JOURNAL OF EXTRA-CORPOREAL TECHNOLOGY 2020; 52:196-202. [PMID: 32981957 DOI: 10.1182/ject-1900039] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 07/16/2020] [Indexed: 12/23/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) has become an effective method in the treatment of adults and children with severe cardiac and pulmonary dysfunction that is resistant to conventional therapy. The aim of this article was to summarize an experience of ECMO usage for cardiac dysfunction, which develops in patients with coronary heart disease (CHD) during percutaneous transluminal coronary angioplasty. The study comprised a retrospective, single-center analysis of 23 patients with CHD (19 men and four women, average age 65.7 ± 12.3 years), who undertook the ECMO technique during percutaneous transluminal coronary angioplasty. A total of 13 (56.52%) patients died directly in the hospital, or 30 days after a discharge. Independent predictors of fatal outcomes were diabetes mellitus (odds ratio [OR] = 17.58; 95% confidence interval [CI] = 6.47-47.48; p = .00125), chronic renal failure (CRF) (OR = 20.81; 95% CI = 5.95-72.21; p = .00014), and damage to the right coronary artery (RCA) (OR = 25.51; 95% CI = 8.27-79.12; p = .00013). For deceased patients, the "no reflow" phenomenon was indicated in a larger percentage of cases (23.1% in the group of deceased, vs. 10% in the group of survivors). A routine connection to ECMO before the occurrence of cardiac events was significantly more often used in the group of survived patients (90% of cases) than in the deceased (p = .0000001). Diabetes mellitus, CRF, and damage to the RCA were independent predictors of mortality during percutaneous transluminal coronary angioplasty in patients with CHD. The routine use of ECMO in high-risk patients with percutaneous transluminal coronary angioplasty was a positive prognostic factor of patient survival.
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12
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Asuka E, Pak S, Thiess AK, Torres A. Gastrointestinal Bleeding as a Complication in Continuous Flow Ventricular Assist Devices: A Systematic Review With Meta-Analysis. J Clin Med Res 2020; 12:543-559. [PMID: 32849943 PMCID: PMC7430922 DOI: 10.14740/jocmr4262] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Accepted: 06/26/2020] [Indexed: 12/24/2022] Open
Abstract
Background The use of ventricular assist devices (VADs) has become predominant in this era of medicine. It is commonly used as a bridge to transplant, recovery and as a destination therapy for patients with severe heart failure, who are not responsive to maximum optimal management or ineligible for transplant. However, several complications are known to occur with the use of these devices. In this research, we will compare gastrointestinal bleeding in patients who used centrifugal flow versus axial flow VADs. We hope that the result of this meta-analysis and the review presented provide adequate information to future researchers, physicians and other healthcare professionals who are interested in this topic. Methods Published articles evaluated for inclusion were obtained from MEDLINE (PubMed), Cochrane, EBSCO, clinicaltrials.gov, and international clinical trials registry. This research was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Procured articles were reviewed by two independent reviewers. Only randomized control trials and observational studies were used. Quality assessment was done with Cochrane Collaboration’s tool (RoB.2 with visualization through robviz) and Newcastle-Ottawa Scale (NOS). Data analysis was carried out with the use of R data analysis tool (version 4.0.0; release date: April 24th, 2020). Results At the end of this meta-analysis, the occurrence of gastrointestinal bleeding was not significantly different between both groups; with odds ratio (OR): 0.81; 95% confidence interval (CI): 0.65 - 1.00; P value = 0.05. Between-study variance (Tau-squared) was zero (0), standard error (SE) = 0.06. The degree of heterogeneity measured with I-squared statistic was 0% (minimal). Egger’s regression test was not statistically significant, P = 0.93. Symmetry of distribution was observed on the funnel plot. Trim and fill analysis showed no missing studies on the left; SE = 1.68. Conclusions The result obtained from this research indicates that the occurrence of gastrointestinal bleeding is not significantly different in both groups of patients, irrespective of the type of continuous flow VAD used. Although, the study sample used in this meta-analysis was limited.
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Affiliation(s)
- Edinen Asuka
- All Saints University School Of Medicine, Hillsborough St, Roseau, Dominica
| | - Stella Pak
- Department of Medicine, Orange Regional Medical Center, 707 East Main Street, Middletown, NY 10940, USA
| | - Armond-Kristopher Thiess
- Department of Medicine, Universidad Autonoma de Guadalajara, Av. Patria 1201, Lomas del Valle 45129, Zapopan, Mexico
| | - Anthony Torres
- Department of Medicine, Universidad Autonoma de Guadalajara, Av. Patria 1201, Lomas del Valle 45129, Zapopan, Mexico
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Extracorporeal membrane oxygenation in the pediatric population - who should go on, and who should not. Curr Opin Pediatr 2020; 32:416-423. [PMID: 32332330 DOI: 10.1097/mop.0000000000000904] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The role of extracorporeal membrane oxygenation (ECMO), a method of providing cardiorespiratory support in instances of cardiac or respiratory failure, in neonates and children continues to expand and evolve. This review details the current landscape of ECMO as it applies to neonates and children. RECENT FINDINGS Specifically, this review provides the most recent evidence for which patients should be considered for the various forms of ECMO including venovenous ECMO, venoarterial-ECMO, and extracorporeal cardiopulmonary resuscitation. Specific topics to be discussed include indications and contraindications for the different types of ECMO in neonates and children, anticoagulation strategies and ways to monitor end-organ function, outcomes specific to the different types and populations with a focus on meaningful survival to discharge and neurologic outcomes, and consideration of special populations such as low birth weight infants, traumatically injured patients, and children who received recent bone marrow transplants. This review also discusses still unanswered questions surrounding the most appropriate use of ECMO as its role and applications continue to evolve. SUMMARY With rapidly increasing utilization of ECMO, neonatologists and pediatricians should be aware of the most recent evidence guiding its indications, applications, and limitations.
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Survival and Cardiopulmonary Resuscitation Hemodynamics Following Cardiac Arrest in Children With Surgical Compared to Medical Heart Disease. Pediatr Crit Care Med 2019; 20:1126-1136. [PMID: 31453988 PMCID: PMC6895416 DOI: 10.1097/pcc.0000000000002088] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To assess the association of diastolic blood pressure cutoffs (≥ 25 mm Hg in infants and ≥ 30 mm Hg in children) during cardiopulmonary resuscitation with return of spontaneous circulation and survival in surgical cardiac versus medical cardiac patients. Secondarily, we assessed whether these diastolic blood pressure targets were feasible to achieve and associated with outcome in physiology unique to congenital heart disease (single ventricle infants, open chest), and influenced outcomes when extracorporeal cardiopulmonary resuscitation was deployed. DESIGN Multicenter, prospective, observational cohort analysis. SETTING Tertiary PICU and cardiac ICUs within the Collaborative Pediatric Critical Care Research Network. PATIENTS Patients with invasive arterial catheters during cardiopulmonary resuscitation and surgical cardiac or medical cardiac illness category. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Hemodynamic waveforms during cardiopulmonary resuscitation were analyzed on 113 patients, 88 surgical cardiac and 25 medical cardiac. A similar percent of surgical cardiac (51/88; 58%) and medical cardiac (17/25; 68%) patients reached the diastolic blood pressure targets (p = 0.488). Achievement of diastolic blood pressure target was associated with improved survival to hospital discharge in surgical cardiac patients (p = 0.018), but not medical cardiac patients (p = 0.359). Fifty-three percent (16/30) of patients with single ventricles attained the target diastolic blood pressure. In patients with an open chest at the start of chest compressions, 11 of 20 (55%) attained the target diastolic blood pressure. In the 33 extracorporeal cardiopulmonary resuscitation patients, 16 patients (48%) met the diastolic blood pressure target with no difference between survivors and nonsurvivors (p = 0.296). CONCLUSIONS During resuscitation in an ICU, with invasive monitoring in place, diastolic blood pressure targets of greater than or equal to 25 mm Hg in infants and greater than or equal to 30 mm Hg in children can be achieved in patients with both surgical and medical heart disease. Achievement of diastolic blood pressure target was associated with improved survival to hospital discharge in surgical cardiac patients, but not medical cardiac patients. Diastolic blood pressure targets were feasible to achieve in 1) single ventricle patients, 2) open chest physiology, and 3) extracorporeal cardiopulmonary resuscitation patients.
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15
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Lorusso R, Raffa GM, Kowalewski M, Alenizy K, Sluijpers N, Makhoul M, Brodie D, McMullan M, Wang IW, Meani P, MacLaren G, Dalton H, Barbaro R, Hou X, Cavarocchi N, Chen YS, Thiagarajan R, Alexander P, Alsoufi B, Bermudez CA, Shah AS, Haft J, Oreto L, D'Alessandro DA, Boeken U, Whitman G. Structured review of post-cardiotomy extracorporeal membrane oxygenation: Part 2-pediatric patients. J Heart Lung Transplant 2019; 38:1144-1161. [PMID: 31421976 DOI: 10.1016/j.healun.2019.07.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 06/19/2019] [Accepted: 07/09/2019] [Indexed: 10/26/2022] Open
Abstract
Veno-arterial extracorporeal membrane oxygenation (ECMO) is established therapy for short-term circulatory support for children with life-treating cardiorespiratory dysfunction. In children with congenital heart disease (CHD), ECMO is commonly used to support patients with post-cardiotomy shock or complications including intractable arrhythmias, cardiac arrest, and acute respiratory failure. Cannulation configurations include central, when the right atrium and aorta are utilized in patients with recent sternotomy, or peripheral, when cannulation of the neck or femoral vessels are used in non-operative patients. ECMO can be used to support any form of cardiac disease, including univentricular palliated circulation. Although veno-arterial ECMO is commonly used to support children with CHD, veno-venous ECMO has been used in selected patients with hypoxemia or ventilatory failure in the presence of good cardiac function. ECMO use and outcomes in the CHD population are mainly informed by single-center studies and reports from collated registry data. Significant knowledge gaps remain, including optimal patient selection, timing of ECMO deployment, duration of support, anti-coagulation, complications, and the impact of these factors on short- and long-term outcomes. This report, therefore, aims to present a comprehensive overview of the available literature informing patient selection, ECMO management, and in-hospital and early post-discharge outcomes in pediatric patients treated with ECMO for post-cardiotomy cardiorespiratory failure.
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Affiliation(s)
- Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Giuseppe Maria Raffa
- Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, IRCCS-ISMETT (Istituto Mediterraneo per I Trapianti e Terapie ad alta specializzazione), Palermo, Italy.
| | - Mariusz Kowalewski
- Department of Cardiac Surgery, Antoni Jurasz Memorial University Hospital, Bydgoszcz, Poland
| | - Khalid Alenizy
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Niels Sluijpers
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Maged Makhoul
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Daniel Brodie
- Division of Pulmonary & Critical Care Medicine, Columbia University, New York, New York
| | - Mike McMullan
- Cardiac Surgery Unit, Seattle Children Hospital, Seattle, Washington
| | - I-Wen Wang
- Cardiac Transplantation and Mechanical Circulatory Support Unit, Indiana University School of Medicine, Health Methodist Hospital, Indianapolis, Indiana
| | - Paolo Meani
- Heart & Vascular Centre, Cardiology Department, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Graeme MacLaren
- Cardiothoracic Intensive Care Unit, National University of Singapore, Singapore
| | - Heidi Dalton
- INOVA Fairfax Medical Centre, Adult and Pediatric ECMO Service, Falls Church, Virginia
| | - Ryan Barbaro
- Division of Pediatric Critical Care and Child Health Evaluation and Research Unit, Ann Arbor, Michigan
| | - Xaotong Hou
- Centre for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Nicholas Cavarocchi
- Surgical Cardiac Care Unit, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Yih-Sharng Chen
- Cardiovascular Surgery & Ped Cardiovascular Surgery, National Taiwan University Hospital, Taipei, China
| | - Ravi Thiagarajan
- Cardiac Intensive Care Unit, Boston Children's Hospital, Boston, Massachusetts
| | - Peta Alexander
- Cardiac Intensive Care Unit, Boston Children's Hospital, Boston, Massachusetts
| | - Bahaaldin Alsoufi
- Department of Cardiovascular and Thoracic Surgery, University of Louisville School of Medicine, Norton Children's Hospital, Louisville, Kentucky
| | | | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jonathan Haft
- Section of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan
| | - Lilia Oreto
- Mediterranean Pediatric Cardiology Center, Bambino Gesù Pediatric Hospital, Taormina, Messina, Italy
| | - David A D'Alessandro
- Cardio-Thoracic Surgery Department, Massachusetts Medical Center, Boston, Massachusetts
| | - Udo Boeken
- Cardiovascular Surgery Unit, University of Düsseldorf, Düsseldorf, Germany
| | - Glenn Whitman
- Cardiovascular Surgery Intensive Care Unit and Heart Transplant, Johns Hopkins Hospital, Baltimore, Maryland
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16
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Bell JL, Saenz L, Domnina Y, Baust T, Panigrahy A, Bell MJ, Camprubí-Camprubí M, Sanchez-de-Toledo J. Acute Neurologic Injury in Children Admitted to the Cardiac Intensive Care Unit. Ann Thorac Surg 2019; 107:1831-1837. [PMID: 30682351 DOI: 10.1016/j.athoracsur.2018.12.027] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2018] [Revised: 11/20/2018] [Accepted: 12/12/2018] [Indexed: 11/17/2022]
Abstract
BACKGROUND Children with acquired and congenital heart disease both have low mortality but an increased risk of neurologic morbidity that is multifactorial. Our hypothesis was that acute neurologic injuries contribute to mortality in such children and are an important cause of death. METHODS All admissions to the pediatric cardiac intensive care unit (CICU) from January 2011 through January 2015 were retrospectively reviewed. Patients were assessed for any acute neurologic events (ANEs) during admission, as defined by radiologic findings or seizures documented on an electroencephalogram. RESULTS Of the 1,573 children admitted to the CICU, the incidence of ANEs was 8.6%. Mortality of the ANE group was 16.3% compared with 1.5% for those who did not have an ANE. The odds ratio for death with ANEs was 8.55 (95% confidence interval, 4.56 to 16.03). Patients with ANEs had a longer hospital length of stay than those without ANEs (41.4 ± 4 vs 14.2 ± 0.6 days; p < 0.001). Need for extracorporeal membrane oxygenation, previous cardiac arrest, and prematurity were independently associated with the presence of an ANE. CONCLUSIONS Neurologic injuries are common in pediatric CICUs and are associated with an increase in mortality and hospital length of stay. Children admitted to the CICU are likely to benefit from improved surveillance and neuroprotective strategies to prevent neurologic death.
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Affiliation(s)
- Jamie L Bell
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Pediatrics, Wayne State University School of Medicine, Detroit, Michigan
| | - Lucas Saenz
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yuliya Domnina
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Tracy Baust
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Ashok Panigrahy
- Department of Pediatric Radiology, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Michael J Bell
- Division of Pediatric Intensive Care, Department of Pediatrics, Children's National Medical Center and the George Washington University School of Medicine, Washington, DC
| | - Marta Camprubí-Camprubí
- Department of Neonatology, Hospital Sant Joan de Déu, Barcelona University, Barcelona, Spain
| | - Joan Sanchez-de-Toledo
- Department of Critical Care Medicine, Children's Hospital of Pittsburgh, University of Pittsburgh, Pittsburgh, Pennsylvania; Department of Cardiology, Hospital Sant Joan de Déu, Barcelona University, Barcelona, Spain.
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17
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Erdil T, Lemme F, Konetzka A, Cavigelli-Brunner A, Niesse O, Dave H, Hasenclever P, Hübler M, Schweiger M. Extracorporeal membrane oxygenation support in pediatrics. Ann Cardiothorac Surg 2019; 8:109-115. [PMID: 30854319 DOI: 10.21037/acs.2018.09.08] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Extracorporeal membrane oxygenation (ECMO) is a general term that describes the short- or long-term support of the heart and/or lungs in neonates, children and adults. Due to favorable results and a steady decline in absolute contraindications, its use is increasing worldwide. Indications in children differ from those in adults. The ECMO circuit as well as cannulation strategies also are individualized, considering their implications in children. The aim of this article is to review the clinical indications, different circuits, and cannulation strategies for ECMO. We also present our institutional experience with 92 pediatric ECMO patients (34 neonates, 58 pediatric) with the majority (80%) of veno-arterial placements between 2014 until 2018. We further to also highlight ECMO use in the setting of cardiac arrest [extracorporeal cardiopulmonary resuscitation (CPR) or eCPR].
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Affiliation(s)
- Tugba Erdil
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University of Zurich, Zurich, Switzerland
| | - Frithjof Lemme
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University of Zurich, Zurich, Switzerland
| | - Alexander Konetzka
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University of Zurich, Zurich, Switzerland
| | - Anna Cavigelli-Brunner
- Children's Research Centre, University of Zurich, Zurich, Switzerland.,Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Oliver Niesse
- Children's Research Centre, University of Zurich, Zurich, Switzerland.,Pediatric Cardiology, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland
| | - Hitendu Dave
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University of Zurich, Zurich, Switzerland
| | - Peter Hasenclever
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University of Zurich, Zurich, Switzerland
| | - Michael Hübler
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University of Zurich, Zurich, Switzerland
| | - Martin Schweiger
- Pediatric Cardiovascular Surgery, Pediatric Heart Center, Department of Surgery, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University of Zurich, Zurich, Switzerland
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18
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Changing Risk of In-Hospital Cardiac Arrest in Children Following Cardiac Surgery in Victoria, Australia, 2007-2016. Heart Lung Circ 2018; 28:1904-1912. [PMID: 30591395 DOI: 10.1016/j.hlc.2018.11.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Revised: 10/18/2018] [Accepted: 11/02/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND Reported incidence of in hospital cardiac arrest (IHCA) after paediatric cardiac surgery varies between 3-4% in high income countries and this risk may have changed over time. We sought to examine this trend in detail. METHODS A retrospective observational study of 3,781 children who underwent 4,938 cardiac surgeries between 1 January 2007 and 31 December 2016 in a tertiary children's hospital. IHCA was defined as cessation of cardiac mechanical activity requiring cardiac massage for ≥1minute. Surgical complexity was categorised using risk adjusted congenital heart surgery (RACHS-1) category. Poisson regression was used to analyse trends for every two-year period. RESULTS There were a total of 211 (4.3%) IHCA events after surgery. These patients were younger, more likely to have had a premature birth, have a chromosomal or genetic syndrome association and have a high surgical complexity. Overall, there was a 52% reduction in IHCA rate over 10 years: reducing from 5.4 /100 surgeries in 2007-08 to 2.6/100 surgeries in 2015-16 (p-trend=<0.001). The reduction was mainly seen in low-to-moderate risk categories (RACHS-1 categories 1-4) and not in high risk categories (RACHS-1 category 5-6). Children in high risk categories were 13.6 times more likely to experience an IHCA (compared to low risk categories). Overall hospital mortality for children suffering IHCA decreased from 42.5/100 patients in 2007-08 to 11.1/100 patients in 2015-16 (p-trend=0.037). CONCLUSIONS The IHCA rate following cardiac surgery has more than halved over the last decade; children who experience IHCA also have lower mortality than in previous years. High risk procedures still have a substantial rate of IHCA and efforts are needed to minimise the burden further in this population.
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19
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National trends in neonatal extracorporeal membrane oxygenation in the United States. J Perinatol 2018; 38:1106-1113. [PMID: 29795325 DOI: 10.1038/s41372-018-0129-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2018] [Revised: 04/06/2018] [Accepted: 04/16/2018] [Indexed: 11/08/2022]
Abstract
OBJECTIVE To determine trends in neonatal extracorporeal membrane oxygenation (ECMO) utilization from 2002-2011. STUDY DESIGN Using the Nationwide inpatient sample (NIS), we conducted a population-based retrospective cohort study to identify ECMO utilization among neonates. Incidence of ECMO utilization, length of stay (LOS), cost and mortality were estimated. RESULT In all, 33,367,146 neonates were identified of which 7603 (18 per 100,000 live births) underwent ECMO. Neonatal ECMO increased from 12 to 23 runs per 100,000 live births. Mortality was 48.4%, decreasing from 47.5 to 41.9% between 2002 and 2011. On multivariate analysis, mortality was significantly higher for infectious indications (OR 4.1; CI 1.1-16.0), E-CPR (OR 3.8; CI 1.4-10.7) and cardiac indications (OR 2.0; CI 1.5-2.8). On hierarchical regression, LOS increased by 1.6 days each year (p = 0.02) and cost of hospitalization increased by $14,033 each year (p < 0.0001). CONCLUSION Neonatal ECMO utilization increased, while mortality decreased during the study period. These findings suggest an improvement in neonatal ECMO care.
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20
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Kubicki R, Höhn R, Grohmann J, Fleck T, Reineker K, Kroll J, Siepe M, Benk C, Klemm R, Humburger F, Stiller B. Implementing and Assessing a Standardized Protocol for Weaning Children Successfully From Extracorporeal Life Support. Artif Organs 2018; 42:394-400. [PMID: 29423912 DOI: 10.1111/aor.13069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Revised: 10/10/2017] [Accepted: 10/10/2017] [Indexed: 11/29/2022]
Abstract
Extracorporeal life support (ECLS) weaning is a complex interdisciplinary process with no clear guidelines. To assess ventricular and pulmonary function as well as hemodynamics including end-organ recovery during ECLS weaning, we developed a standardized weaning protocol. We reviewed our experience 2 years later to assess its feasibility and efficacy. In 2015 we established an inter-professional, standardized, stepwise protocol for weaning from ECLS. If the patient did not require further surgery, weaning was conducted bedside in the intensive care unit (ICU). Most of the weaning procedures are guided via echocardiography. Data acquisition began at baseline level, followed by four-step course (each step lasting 10 min), entailing flow-reduction and ending 30 min after decannulation. Moreover, data from the preprotocol era are presented. Between May 2015 and 2017, 26 consecutive patients (18 male), median age 177 days (2 days-20 years) required ECLS with median support of 4 (2-11) days. Excluding eight not weanable patients, 21 standardized weaning procedures were protocolled in the remaining 18 children. Our generally successful protocol-guided weaning rate (with at least 24-h survival) was 89%, with a discharge home rate of 58%. Practical application of the novel standard protocol seems to facilitate ECLS weaning and to improve its success rate. The protocol can be administered as part of standard bedside ICU assessment.
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Affiliation(s)
- Rouven Kubicki
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg - Bad Krozingen, Freiburg, Germany
| | - René Höhn
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg - Bad Krozingen, Freiburg, Germany
| | - Jochen Grohmann
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg - Bad Krozingen, Freiburg, Germany
| | - Thilo Fleck
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg - Bad Krozingen, Freiburg, Germany
| | - Katja Reineker
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg - Bad Krozingen, Freiburg, Germany
| | - Johannes Kroll
- Department of Cardiovascular Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Matthias Siepe
- Department of Cardiovascular Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Christoph Benk
- Department of Cardiovascular Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Rolf Klemm
- Department of Cardiovascular Surgery, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Frank Humburger
- Department of Anesthesiology and Critical Care, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg - Bad Krozingen, Freiburg, Germany
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Abstract
The use of extracorporeal support after failed return of a spontaneous ciruculation during cardiopulmonary resuscitation (ECPR) is well described. There are 4 distinct phases for resuscitation with ECPR and the time spent in each phase is critical for successful outcome. Recommendations for ECPR previously published by the American Heart Association provide the context for implementing a consistent and well-rehearsed system for ECPR, by people with the knowledge, experience and resources to deploy ECPR in the most optimal time frame possible in selected patient populations. In this manuscript we review the current status of ECPR for acute cardiac failure and the components we believe are necessary to develop and sustain a reliable and resilient program.
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Affiliation(s)
- Peter C Laussen
- Department of Critical Care Medicine, Department of Anaesthesia, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Anne-Marie Guerguerian
- Department of Critical Care Medicine, Department of Paediatrics, University of Toronto, ON, Canada
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22
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Abstract
Extracorporeal membrane oxygenation (ECMO) or extracorporeal life support (ECLS) is a form of heart lung bypass that is used to support neonates, pediatrics, and adult patients with cardiorespiratory failure for days or weeks till organ recovery or transplantation. Venoarterial (VA) and venovenous (VV) ECLS are the most common modes of support. ECLS circuit components and monitoring have been evolving over the last 40 years. The technology is safer, simpler, and more durable with fewer complications. The use of neonatal respiratory ECLS use has been declining over the last two decades, while adult respiratory ECLS is growing especially since the H1N1 influenza pandemic in 2009. This review provides an overview of ECLS evolution over the last four decades, its use in neonatal, pediatric and adults, description of basic principles, circuit components, complications, and outcomes as well as a quick look into the future.
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Affiliation(s)
- Tejas Mehta
- Pediatric Intensive Care Unit, Department of Pediatrics, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar. www.hamad.qa
| | - Ahmed Sallehuddin
- Pediatric Intensive Care Unit, Department of Pediatrics, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar. www.hamad.qa
| | - Jiju John
- Pediatric Intensive Care Unit, Department of Pediatrics, Hamad Medical Corporation, P.O. Box 3050, Doha, Qatar. www.hamad.qa
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Kajimoto M, Ledee DR, Isern NG, Portman MA. Right ventricular metabolism during venoarterial extracorporeal membrane oxygenation in immature swine heart in vivo. Am J Physiol Heart Circ Physiol 2017; 312:H721-H727. [PMID: 28159812 DOI: 10.1152/ajpheart.00835.2016] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2016] [Revised: 01/17/2017] [Accepted: 01/29/2017] [Indexed: 12/28/2022]
Abstract
Venoarterial extracorporeal membrane oxygenation (VA-ECMO) provides hemodynamic rescue for patients encountering right or left ventricular (RV or LV) decompensation, particularly after surgery for congenital heart defects. ECMO, supported metabolically by parenteral nutrition, provides reductions in myocardial work and energy demand and, therefore, enhances functional recovery. The RV must often assume systemic ventricular pressures and function on weaning from VA-ECMO. However the substrate utilization responses of the RV to VA-ECMO or stimulation are unknown. We determined RV and LV substrate utilization response to VA-ECMO in immature swine heart. Mixed-breed male Yorkshire pigs (33-49 days old) underwent normal pressure volume loading (control, n = 5) or were unloaded by VA-ECMO (ECMO, n = 10) for 8 h. Five pigs with ECMO received intravenous thyroid hormone [triiodothyronine (T3)] to alter substrate utilization. Carbon 13 (13C)-labeled substrates (lactate and medium-chain and long-chain fatty acids) were systemically infused as metabolic tracers. Analyses by nuclear magnetic resonance showed that both ventricles have similar trends of fractional 13C-labeled substrate contributions to the citric acid cycle under control conditions. VA-ECMO produced higher long-chain fatty acids and lower lactate contribution to the citric acid cycle via inhibition of pyruvate dehydrogenase, whereas T3 promoted lactate metabolism in both ventricles. However, these metabolic shifts were smaller in RV, and RV fatty acid contributions showed minimal response to perturbations. Furthermore, VA-ECMO and T3 also achieved high [phosphocreatine]/[ATP] and low [NADH]/[NAD+] in LV but not in RV. These data suggest that the RV shows decreased ability to modify substrate utilization and achieve improvements in energy supply/demand during VA-ECMO.NEW & NOTEWORTHY We showed that the right ventricle unloaded by venoarterial extracorporeal membrane oxygenation (VA-ECMO) has diminished capacity to alter substrate utilization compared with the left ventricle. This decrease in metabolic flexibility contributes to the inability to increase high-energy phosphate reserves during myocardial rest by VA-ECMO.
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Affiliation(s)
- Masaki Kajimoto
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington
| | - Dolena R Ledee
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington
| | - Nancy G Isern
- Environmental Molecular Sciences Laboratory, Pacific Northwest National Laboratories, Richland, Washington; and
| | - Michael A Portman
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Washington; .,Division of Cardiology, Department of Pediatrics, University of Washington, Seattle, Washington
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